Nursing documentation guides
Plain-language guides to charting formats, assessments, handover and specialty documentation. Each guide links to a free template you can practise with.
What Is Nursing Documentation? Purpose, Types and StandardsWhat nursing documentation is, why it matters for safety and continuity of care, the main charting formats, and the standards that shape it.How to Write Nursing Notes: A Practical Guide with ExamplesHow to write clear, objective nursing notes: what to include, words to avoid, timing, and fictional before-and-after examples.SOAP Notes for Nurses: Format, Tips and a Fictional ExampleSOAP and SOAPIE notes explained for nurses: what goes in Subjective, Objective, Assessment and Plan, with a fictional worked example.SBAR in Nursing: How to Use It for Calls and HandoverHow to structure SBAR communication in nursing: what to say in Situation, Background, Assessment and Recommendation, with a fictional example call.DAR Focus Charting: Data, Action, Response ExplainedWhat DAR focus charting is, how to choose a focus, and how to write Data, Action and Response entries, with a fictional example.How to Write a Nursing Care Plan Using ADPIEStep-by-step guide to writing a nursing care plan using the nursing process: assessment, diagnosis, planning with SMART goals, implementation and evaluation.Writing a Nursing Diagnosis in PES FormatHow to write a nursing diagnosis using Problem, Etiology and Signs and symptoms, including risk diagnoses and common errors.Head-to-Toe Assessment Documentation: A System-by-System GuideHow to document a head-to-toe nursing assessment, system by system, with examples of specific, objective wording.Pain Assessment Documentation: Scales, OLDCARTS and ReassessmentHow nurses document pain: choosing a scale, using OLDCARTS or PQRST, recording interventions and documenting reassessment.Nursing Brain Sheets: How to Organise Your ShiftWhat a nursing brain sheet is, what to include, how to use it through a shift, and how to handle it safely.12 Common Nursing Documentation Mistakes and How to Avoid ThemThe documentation errors nurses and students make most often, from vague wording to missing notifications, and practical ways to avoid them.Late Entries and Corrections in Nursing DocumentationHow to write a late entry, correct an error and amend an electronic record without altering the original, following facility policy.Do-Not-Use Abbreviations in Nursing DocumentationThe abbreviations on The Joint Commission's official do-not-use list, why they cause errors, and what to write instead.Wound Documentation: How to Measure and Describe a WoundHow nurses document wounds: measurement, undermining and tunnelling with the clock method, tissue types, exudate, periwound skin and treatment.Pressure Injury Staging and DocumentationThe NPIAP pressure injury stages explained for documentation, plus risk assessment, prevention and why pressure injuries are not reverse-staged.Medication Administration Documentation for NursesHow to document medication administration safely: the rights of medication administration, held and refused doses, PRN effectiveness and reconciliation.Nursing Student Clinical Paperwork: What to Expect and How to PrepareA guide to the paperwork nursing students complete on clinical placement: prep sheets, care plans, concept maps, medication research, logs and reflections.How to Write Home Health Visit NotesWhat to include in a home health nursing visit note: visit details, assessment, home environment, teaching with teach-back and the plan.