Nursing Charting Guides
Practical charting frameworks for clinical, psychiatric, and cross-cutting nursing documentation.
Clinical
How to Score and Document a Glasgow Coma Scale Assessment (Nursing Guide)
This guide assists nurses in scoring and documenting the Glasgow Coma Scale. It covers the 15-point scale, severity thresholds, documentation examples, and what to chart when the score drops.
Braden Scale Scoring and Wound Documentation for Nurses
How to score and document the Braden Scale, plus wound assessment documentation. 6 subscales, intervention thresholds by score, wound bed composition, and a full example.
Clinical Nursing Charting: The Complete Guide for Every Specialty
The 8 categories every clinical nurse documents on every shift - vitals, fall risk, head-to-toe, wound care, and more. With links to deep guides for each.
How to Document a Head-to-Toe Assessment (With a Full Example)
How to document a complete head-to-toe nursing assessment by body system. Within Defined Limits framework, 10 body systems, and a full example you can model yours on.
Patient Education and Nursing Notes Documentation: The Complete Guide
Learn how to document patient education, discharge teaching, and narrative nursing notes. Explore required elements, the teach-back method, and view a complete example.
Patient Safety Check Documentation: Nursing Hourly Rounding Guide
Learn how to document hourly rounding, safety checks, and fall precautions. Discover what to chart for each round, identify common mistakes, and review a full shift example.
Vital Signs Documentation: A Nursing Guide to Efficient Charting
How to document vital signs efficiently while ensuring defensibility. BP, HR, RR, SpO2, temp, pain - including trending, abnormal reporting, and a comprehensive example.
How to Score and Document the Morse Fall Scale (Nursing Guide)
Learn to score the Morse Fall Scale, interpret risk levels, and document fall risk assessments. Explore all 6 subscales, intervention thresholds, and an example.
Documenting IV Site Assessments and IV Insertion (Nursing Guide)
Learn how to document peripheral IV insertion, site assessments, dressing changes, and complications. Discover what to chart for each check, along with an example.
SBAR for Clinical (Med-Surg) Nursing: A Complete Example
SBAR for clinical and med-surg handoffs. How clinical SBAR differs, what to include for vital signs trending and assessments, and a full fictional example.
Psychiatric
CIWA and COWS Documentation: A Nursing Guide to Withdrawal Scoring
How to score and document the CIWA-Ar and COWS withdrawal assessments. 10 CIWA items, 11 COWS items, scoring examples, and protocol-triggered interventions.
Psychiatric Nursing Charting: Everything You Need to Document on a Psych Unit
The 8 categories psych nurses document include mental status, safety, thought process, CIWA/COWS, and more. This section provides examples, highlights common mistakes, and offers links to in-depth guides.
Documenting a Mental Status Exam: A Nursing Guide
The complete nursing guide to documenting a Mental Status Exam. All 10 MSE components, what to observe, and a full example chart entry.
Documenting Thought Processes and Behaviors in Psychiatric Nursing
The nursing guide to documenting thought process (tangentiality, loose associations), thought content (delusions, hallucinations), and observed behaviors.
End-of-Shift Nursing Note: How to Write a Complete Narrative
How to write a narrative end-of-shift nursing note. The 5 required elements, when to use narrative vs. structured fields, and a full example.
Charting Suicidal Ideation and Safety Assessments: A Nursing Guide
How to document suicidal ideation, homicidal ideation, auditory hallucinations, 1:1 observation, and safety plans. Required elements, standardized tools, and an example.
Documenting Activities of Daily Living (ADLs) in Nursing
How to document ADLs (Activities of Daily Living) in nursing - bathing, dressing, toileting, eating, mobility. Level of independence and specific examples.
SBAR for Psychiatric Nursing: A Complete Example
SBAR for psychiatric handoffs. How psych SBAR differs from clinical SBAR, a complete fictional example, and the 3 things psych nurses forget to include.
Documenting the Therapeutic Milieu on a Psych Unit
Psychiatric nurses document the therapeutic milieu, unit environment, and patient on/off unit status. They observe awake/asleep gate, make milieu observations, and provide an example.
Documenting Speech and Patient Interactions in Psychiatric Nursing
Learn to document speech patterns (rate, volume, pressured speech) and patient interactions with staff, peers, and groups in psychiatric nursing.
Universal
The Complete Nursing Charting Cheat Sheet
Chart all essential aspects, including vitals, wound care, mental status, and SBAR handoff. Explore 16 categories in this scannable reference, and download the free PDF.
SBAR Nursing Handoff: The Complete Guide (With Examples)
The complete guide to SBAR handoff reports for nurses. Structure, examples, common mistakes, and a full fictional handoff you can model yours on.
The New Nurse Charting Survival Guide
Your first shift starts tomorrow and you're not sure what to chart. This is the framework I wish I'd had before mine. Clinical, psych, or somewhere in between.
Charting Mistakes That Can Actually Cost Your Nursing License (and the Ones That Won't)
Identify which charting errors jeopardize your license and which do not. This guide distinguishes real risks, such as falsification and missed safety, from unnecessary anxiety.
AI Nursing Notes: What Nurses Should Actually Know
A straightforward guide to AI-assisted nursing documentation. It covers three types of AI tools, HIPAA concerns, the capabilities and limitations of AI, and how to evaluate any tool.