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. Covers required elements and the teach-back method, with a complete worked example.
Patient Safety Check Documentation: Nursing Hourly Rounding Guide
Learn how to document hourly rounding, safety checks, and fall precautions. Covers what to chart for each round and walks through a full shift example with common mistakes flagged inline.
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.
FLACC Pain Scale: Nursing Guide for Nonverbal Pain Assessment
The nursing guide to the FLACC pain scale. Scoring criteria for each category, when to use it, how to document a FLACC score, and a fictional example.
How to Score and Document a RASS Assessment (Nursing Guide)
How to score and document the Richmond Agitation-Sedation Scale. Full -5 to +4 range, the three-step assessment, and what to chart at every titration.
BPS Pain Scale: Nursing Guide for Ventilated Adult ICU Patients
The nursing guide to the Behavioral Pain Scale. The 3 BPS domains, the 3 to 12 score range, when to pair it with RASS, and how to chart it in a sedated ventilated adult.
CPOT Pain Scale: Nursing Guide for Critically Ill Adult ICU Patients
The nursing guide to the Critical-Care Pain Observation Tool. The 4 CPOT domains, the 0 to 8 score range, when to use CPOT instead of BPS, and how to chart it on a non-intubated ICU patient.
PAINAD Pain Scale: Nursing Guide for Non-Verbal Patients with Advanced Dementia
The nursing guide to the Pain Assessment in Advanced Dementia scale. The 5 PAINAD domains, the 0 to 10 score range, when to use it instead of self-report, and how to chart it on a med-surg or memory-care unit.
Psychiatric
CIWA-Ar Documentation: A Nursing Guide to Alcohol Withdrawal Scoring
How to score and document the CIWA-Ar alcohol withdrawal assessment. 10 items, scoring examples, and protocol-triggered interventions for nurses.
COWS Documentation: A Nursing Guide to Opioid Withdrawal Scoring
How to score and document the COWS opioid withdrawal assessment. 11 items, scoring examples, and protocol-triggered MAT induction interventions for nurses.
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 walks through examples and links to the in-depth guide for each category.
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.
How to Score and Document a PHQ-9 (Nursing Guide)
Learn how to score and document the Patient Health Questionnaire-9. This guide covers the 9 items, severity bands, and necessary documentation when item 9 is positive.
How to Score and Document a GAD-7 (Nursing Guide)
Learn how to score and document the GAD-7 anxiety screen. This tool includes seven items and severity bands, and it also screens for SAD, panic, and PTSD.
How to Score and Document a C-SSRS (Nursing Guide)
How to score and document the Columbia Suicide Severity Rating Scale. The 5 ideation questions, the 5 behavior categories, and what to chart for each.
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 Medical Scribes and AI Nursing Notes: What Nurses Should Actually Know
Honest guide to AI medical scribes and AI nursing notes for nurses. Covers tool types, HIPAA, what AI can and cannot do, and how to evaluate any scribe.
Objective vs Subjective Nursing Data: A Charting Guide
Learn the difference between objective and subjective nursing data, what belongs in structured fields vs narrative notes, and how to chart both cleanly.