Chart Like a Boss for Nurses
The New Nurse's Charting Guide with 42 Before-and-After Notes, SBAR Scripts, Report Sheets, and Cheat Sheets for Legally Defensible Documentation
"You were taught how to nurse. You were never really taught how to chart it. Here are the words: 42 real before-and-after notes, tear-out report sheets, and 10 cheat sheets for fast, legally defensible documentation.
You were taught how to nurse. You were never really taught how to chart it. Every shift you make a hundred good calls, then have to prove them in a box a stranger will read two years from now. This is the book that shows you the words.
Inside are 42 real before-and-after notes (the version that usually gets written beside the version that still holds up cold, months later), 5 tear-out report sheets for Med-Surg, ICU, ER, and Tele, and 10 cheat sheets you will actually use at 0300: SBAR with read-back, the Never-Chart list, safe abbreviations, and the Fix-It decision tree. It is legally defensible without the fear: what is a law, what is an accreditor's standard, and what is simply how most units do it, told straight.
It reads like a veteran nurse pulling you aside, not a textbook. You already know how to care for the patient. This shows you how to write it so it counts. Chart clearly. Leave calm. Go home.
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You were taught how to nurse. You were never taught how to chart it.
Every shift you make a hundred good calls, then have to prove them in a box a stranger will read two years from now, someone who remembers neither the shift nor you. Documentation runs the job, and almost nobody is taught how to do it well: not the forms, which anyone learns in a week, but the thinking underneath them. What to write. What to leave out. How to build a note that still holds up cold.
What is inside
- 42 real before-and-after notes. The weak version beside the version that holds up. The examples are the product.
- The exact words for the moments that scare you: a fall, a refusal, a patient who just does not look right, a late entry you have to fix the right way.
- 5 tear-out report sheets: Med-Surg, ICU, ER, Tele, and a build-your-own brain sheet.
- 10 cheat sheets: SBAR with read-back, the Never-Chart list, safe abbreviations, the Fix-It decision tree, a head-to-toe template, and more.
- Legally defensible without the fear: what is a law, what is an accreditor's standard, and what is just unit habit, told straight so you always know which rule you are following and why.
Twelve chapters, four parts
What a good note actually is; speed and sanity on a busy shift; charting the hard moments (falls, refusals, codes, skin and lines, calling a provider); and how to fix it when it goes wrong. Every rule that matters arrives with a real note attached, because a rule you cannot see inside a real note is a rule you will not reach for at 0300.
This book is for you if you are
A new grad who was never shown the ropes on documentation, a nurse switching units or returning to the bedside, a preceptor who wants something real to hand a student, or anyone who has stared at a blank note too tired to find the words.
The first book in the RN Guides collection
From The Nursing Library. One working part of the job per book. The examples are the product. The pages come out. Your license outranks the book.
Chart clearly. Leave calm. Go home.
- ISBN-13
- 9781917754668
- ISBN-10
- 1917754663
- Pages
- 313
- Dimensions
- 6 x 0.71 x 9 inches
- Weight
- 1.19 pounds
- Language
- English
- Publisher
- The Nursing Library
- Published
- Author
- Linda Delaney