RN Guides · Book 01
Two notes. Same patient. One ends a career.
Chart Like a Boss for Nurses teaches documentation the way it is actually defended: 42 worked before-and-after notes, SBAR scripts and printable report sheets, for the nurse with six minutes and eleven charts left.
313 pages · 12 chapters · 42 worked notes · 10 cheat sheets · 5 report sheets
The same fall, charted two ways
Pt fell in bathroom. Assisted back to bed. Appears OK. Will monitor.
Called to room by call light. Pt found on floor beside bathroom door, supine, awake, oriented x4. States “I was reaching for the towel.” No LOC witnessed or reported. Head-to-toe completed: no visible injury, no deformity, ROM intact x4 extremities. VS 138/82, HR 88, RR 18, T 98.2, SpO2 96% RA. Assisted to bed x2 staff. Provider notified 0724, no new orders. Neuro checks q15min x1hr per protocol. Call light within reach, bed low and locked.
The marks show the three moves the chapter teaches: what you observed rather than what you concluded, an absence stated honestly, and a notification with a time on it.
The book
The collection
Reference guides for people who are already on shift
The Nursing Library publishes one kind of book: a practical guide a nurse can use on the floor, written against named standards, with worked examples rather than theory.
- RN Guides Practical reference guides for registered nurses, from the first shift onward.
- NP GuidesIn preparation.
- Student GuidesIn preparation.
Inside the book
Forty-two pairs like this one
Every chapter teaches one rule and then shows it applied to a real note. This pair is from the chapter on describing what you saw instead of what you concluded.
Pt non-compliant with incentive spirometer.
Incentive spirometer offered at 2140. Pt declined, stating “it hurts too much when I breathe in that deep.” Pain 7/10 at incision on assessment. Analgesia per PRN order given 2145; re-offer planned at 2230 once the medication has had time to work.
“Non-compliant” is a conclusion about the patient. “Declined, stating” is an observation, and it is the one that holds up.
Free pack
Every sheet in the back of the book, printable
Ten cheat sheets, five report sheets and the printable brains. Select your book, enter your details, and the whole pack is yours.
- Report sheet
The one-patient brain
Single patient, full shift, fits a scrub pocket folded twice.
- Report sheet
The five-patient brain
Med-surg ratio. Room, code status, lines, times due, and one line for the thing you must not forget.
- Cheat sheet 10
Descriptor dictionary
The words that describe what you saw, replacing the words that describe what you concluded.
- Cheat sheet
SBAR call script
What to have in your hand before you call the provider at 0300.
Standards
How these books are written
- Clinical and documentation guidance is written against named, checkable sources: The Joint Commission’s Do Not Use list, ISMP error-prone abbreviations, and the governing state Nurse Practice Act.
- Every worked note is checked against the rule it is teaching, and against the other notes in the book, so the examples never contradict each other.
- These are practical guides, not legal or clinical advice. Where this book and your facility’s policy disagree, your policy wins, every time.
- Scope of practice varies by state and by employer. Nothing here overrides your own licence, your chain of command, or your unit’s standing orders.