Chart This! — A Nurse’s Guide to Documenting What Matters Most

Real examples. Real nursing. Real impact.

Ever finish an assessment, know exactly what happened with your patient…and then stare at the narrative box wondering what you’re supposed to write?

Chart This! was created to help bridge that gap.

This practical nursing documentation guide and workbook helps nurses take what they observed, assessed, did, taught, communicated, and followed up on—and turn it into documentation that tells the clinical story clearly.

Using the OAIERP Method — Observe, Assess, Intervene, Educate, Respond, Plan — you’ll learn how to organize your clinical thinking and recognize what actually belongs in the note.

Inside you’ll find:

• Narrative charting fundamentals

• Subjective vs. objective documentation

• Baseline vs. change

• The OAIERP Method

• Weak-to-strong documentation examples

• Charting language support

• Patient education and teach-back documentation

• Provider notification and clinical communication

• Wound, skin, and dressing-change documentation

• 12 clinical documentation templates

• 12 realistic “Chart This!” practice cases

• Answer examples and guided practice

• Real-world documentation situations

• Quick-reference tools for charting on the job

This resource was created for new nurses, home health nurses, LTC/SNF nurses, nurses building charting confidence, and anyone who wants clearer, more organized documentation.

DIGITAL PRODUCT: You will receive a PDF digital download. No physical product will be mailed. The guide may be viewed digitally or printed for personal use.

Educational Disclaimer: This resource is intended for educational and informational purposes only. It does not replace employer policies, facility or agency requirements, applicable laws or regulations, payer requirements, scope-of-practice standards, or individual clinical judgment.