The Nursing Library
Documentation
that holds up
We publish one thing, and we try to publish it better than anyone: the most practical charting reference a working nurse can carry on shift.
Why
Most charting advice cannot be used at 0300
It is written to be agreed with, not applied. It describes what good documentation is like instead of showing you one. So it reads well in a classroom and evaporates the moment a patient deteriorates and you have four minutes to write it up.
Our answer is the worked note: the same entry written twice, before and after, with the reason for every change visible. You are not asked to believe the advice. You can see it.
Example
This is the whole method, in one pair
Pt c/o pain. Medicated. Will continue to monitor.
Pt reports RLQ pain 8/10, sharp, worse on movement, new since 2100. Guarding noted. Oxycodone 5 mg PO given per order. Dr. Aziz paged 2142. Reassess 2210.
Same shift, same patient, same four minutes. The second one is what a reviewer, a colleague at 0700, and a lawyer two years later all need it to say.
Contents
What is in the library
- Books Reference guides built around worked notes, printable sheets and shift-ready plans. 1 book published
- Free resources Every card in the back of the book, free to print as many times as you want.
- Tools Printable self-checks and structured guides, built around real notes. In preparation
In the book
What that adds up to
- 42
- Worked before-and-after notes
- 10
- Printable cheat sheets
Standards
How these books are written
- Worked, not described. Every technique appears as a real note, shown before and after. If it cannot be demonstrated on a note, it does not go in the book.
- Named sources, not vibes. Where a rule comes from a published standard, such as the Joint Commission "Do Not Use" list or the ISMP error-prone abbreviation list, the book names it, so you can check it and cite it.
- Written to be used mid-shift. Reference first, reading second. The sheets are built to be printed, folded, and carried, then reprinted when the first one goes soft in a pocket.
- No clinical advice. These are documentation guides. They tell you how to write what happened; they never tell you what care to give, and they are not a substitute for your facility’s policy.
Next
Chart with confidence
Whether you are writing a note you might have to defend, or handing off at 0700, start here.