161 articles · 379 decisions cited
What to write, and what gets read back to you
129 of the 161 stand on a court decision you can open and read yourself. Written by a nurse who is still on the floor. How this guide is made
Teaching this, or briefing a unit? The whole guide as a lesson in one sheet: ten rules and examples, free to print and hand out.
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Charting a fall?
Here from the “You charted patient fell” video? Start here.
- What to write after a fallThe post-fall note: chart what you saw and what you checked.
- “Patient fell.” What a lawyer asksThe questions your fall note gets in a deposition, from real cases.
- “No injury noted.”What an expert asks about a post-fall note, and what to chart instead.
- “Fall precautions in place.”Which precautions, checked when? Three real cases, and what to chart instead.
What are you charting right now?
- A patient fell
- Refused care or left AMA
- The provider didn't call back
- You're charting late
- A note you signed is wrong
- Filing an incident report
- An unsafe assignment
- You got written up
Teaching or precepting? Words to avoid in a nursing note, a free one-page handout.
Everything, by situation
Any note: how it gets read29The habits that weaken any note: vague words, the WNL box, copy-forward, AI drafts, the flowsheet that disagrees.
- Words to never chart in a nursing noteCharting phrases that leave more questions than answers
- Exceptions to WDL in nursing: meaning and how to chartWhat WNL covers, and what still needs its own entry
- Copy-paste charting: why cloned notes stop countingCopied nursing notes: what still belongs in today’s assessment
- Charting that a doctor did not respond, without blameWho said what, what actually happened, and what you did next
- Charting a preliminary or unclear lab resultChart unclear lab results without making them sound settled
- Charting the patient response, not just the interventionReassessment notes that show more than a completed task
- Signing an AI-drafted nursing noteHow to review AI nursing notes before your name gets stapled to fiction
- When the EHR box does not match the patientWhen the checkbox is close enough to become wrong
- When your flowsheet and your note tell different storiesFlowsheet says one thing, the note says another: which one the chart believes
- The assessment you could not finishHow to chart the head-to-toe you couldn't finish without a blank or a fake WNL
- Charting pain when your patient can't give you a numberCharting FLACC, CPOT and PAINAD so the score and the dose actually add up
- When the patient doesn't want the room listened toCharting consent, declines and mid-shift withdrawal for ambient AI documentation
- When you acted on the AI summary instead of the chartWhat to chart when the AI summary said one thing and the chart said another
- Checking monitor vitals before they go into the chartAuto-filed vitals, artifact, and the recheck that has to sit right next to it
- Charting a seizure you're not sure is realWhat to chart when a seizure doesn't look real, and the words to leave out
- Denies, never asked, and could not ask in the admission historyWhat 'denies' should mean on an admission history, and what to chart when it doesn't
- When the patient tells you about a history the chart doesn't haveCharting the history the family remembers and the EHR doesn't
- When to use the patient's exact wordsWhen to chart the patient word for word, and what a label like refused leaves out
- When you charted it in a place nobody opensFloating on an unfamiliar EHR: how to chart a finding so someone actually sees it
- How to chart mental status so the note still makes sense years laterWhy confused and A&O x4 fall apart years later, and what to chart instead
- What the intubated patient told you without wordsCharting nods, squeezes and letter boards without turning them into quotes
- Bed alarm on, call light in reach, and other lines you did not checkAuto-filled fall precautions, and why a line you never checked can't vouch for you
- When the score says low risk and you do not believe itCharting a low risk score when your own assessment says otherwise
- The patient will read your note in the portal tonightCharting for the reader who was in the room: the patient, now with portal access
- When a patient asks you to keep it out of the chartWhat to do when a patient asks you to keep it out of the chart
- When the parent can read the teen's chartTeen confides, parent has proxy access: where the chart leaks and how to write around it
- Entering an allergy the patient tells you aboutCharting allergies so the next nurse can tell hives from a stomachache
- Stated weight or measured weight: chart which one you haveStated weight vs measured weight, and why the chart has to say which
- How to chart vitals someone else tookCharting vitals the aide, the student, or the day nurse took
Everyday charting23Falls, restraints, wounds, held doses, transfusions, lines and drains, discharge teaching.
- Documenting a patient fall: the post-fall noteoften openedAfter a fall: chart what you saw and what you checked, and nothing you didn't
- Restraint documentation for nursesRestraint charting that still holds together when someone lines it up against the event
- Wound and pressure injury documentationHow to chart a wound so the next nurse can see it without lifting the dressing
- Documenting a held medication doseHeld insulin, heparin or metoprolol: chart the number, the reason and the name
- Documenting a change in condition and rapid responseCharting a rapid response: the times, the calls, the responses, and the words that hurt you
- Documenting discharge teaching and teach-backCharting discharge teaching so it shows what the patient said and did
- Documenting IV infiltration and extravasationIV infiltration and extravasation: what to chart so the note can answer for you
- Blood transfusion documentation for nursesTransfusion charting: clock times, vitals, and what to write when a reaction starts
- Documenting critical lab value notificationCritical lab values: chart the call so it still exists after the shift ends
- Documenting interpreter useInterpreters and family translators: what the chart has to show
- Documenting lines, drains and tubesIVs, drains, tubes: what to chart every shift so the record shows you looked
- Documenting patient belongings and valuablesHow to chart patient belongings so a missing ring doesn't become your problem
- Charting an unexpected death so the timeline holdsCharting an unexpected death: last seen, found, called, pronounced, family told
- Taking over a running opioid or midazolam drip at shift changeTaking over a fentanyl, PCA or midazolam drip: what to chart before you touch the pump
- The skin check at the start of your shiftCharting a start-of-shift skin check that still holds up after a bruise turns up
- The turns you charted every two hoursHow to chart q2h turns, refusals and late turns so the log matches the night you had
- Charting for a patient on a clinical trialStudy patients: chart doses, draws and symptoms at the real clock time
- The meal percentage and fluid intake nobody adds upMeal percentages and fluid totals: the math nobody does until a lawyer does
- When the care plan says every two hours and the floor can't keep upCharting the gap when the care plan says q2h and the night shift can't
- The bath that did not happen and the code you picked for itThe shower didn't happen. The drop-down wants a reason, and refused is rarely the true one
- Charting the trach on a solo home vent shiftCharting trach and vent checks when you're the only nurse in the house
- Charting the medication your patient brought from homeHome meds: what to chart before the patient's pill bag becomes the next shift's mystery
- The ventilator settings you charted but did not setWhy 'per RT' isn't a vent check, and what to chart instead
Timing: late, during a code, on paper12When you charted is not when it happened. Late entries, charting after a code, downtime on paper.
- Charting in real time vs at end of shiftEvent time, entry time, and the shift that kept them apart
- Late entry charting: adding a note after your shiftMissed a note? Add the facts without rewriting the record
- Altering a medical record: what spoliation meansCorrect nursing notes without erasing when the facts became known
- When the billable visit did not happenHow to chart missed, shortened, or interrupted visits without feeding the billing goblin
- Charting during a code when your hands were fullHow to chart a code when care came first and the timestamps came later
- Charting on paper when the system goes downoften openedDowntime charting: paper care entered at the right time, once, with a label
- One group, twelve notes, twelve different patientsOne group, twelve names, one paragraph pasted twelve times, and why that fails
- Chart it after you do itWhy the 0900 med pass shouldn't go in at 0805, and what to chart instead
- When your clock-In and your note disagreeEVV says four hours, your note says one: what to write so neither looks made up
- Your contract ends before your notes are finishedLast shift on contract: sign everything before your EHR access shuts off
- Finishing your charting from home without making it look made upCharting from home so your note and the audit log tell the same story
- Charting care you gave after your shift endedCharting the care you gave after report, under your own name and your own clock
When something goes wrong with a patient or a med41Refusal and AMA, incident reports, waste, a dose that is not there, a provider who never called back.
- Is an incident report discoverable? Never chart itIncident reports and clinical notes: separate documents, no missing care
- How to document a patient refusal and AMAoften openedRefusal notes: the decision, the discussion, and what happened next
- Assignment Despite Objection: what to file and what to chartWhere the staffing objection goes, and what still belongs in the patient chart
- How to chart when the doctor does not call backWhat to chart when the callback never comes and the shift keeps moving
- You pulled the medication but never gave itPulled but never given: closing the MAR and return or waste records
- Charting intrusive thoughts a patient reportsHow to chart intrusive self-harm or harm thoughts without flattening the risk picture
- How to document controlled substance wasteChart the dose, the waste, the witness, and the math before the system gets creative
- When the medication is not on the MARHow to chart a med that exists everywhere except the MAR
- When the patient says the charted pain dose was not givenWhen the MAR says given and the room says otherwise
- When a syringe or vial looks wrong before you give itHow to chart the vial, bag, syringe, or label that makes your stomach blink
- When the new EHR is missing old informationGo-live ate the MAR. Chart what's missing, your source, and who you told
- When a patient says they might hurt someoneChart the threat picture, not just the scary abbreviation
- Charting suicide precautions so the record shows actual observationChart q15 and 1:1 suicide precautions as actual observation, not checkbox theater
- When the dose was given but the MAR missed itFix a missed MAR entry without inventing a cleaner timeline
- When the family finds a bruise you did not chartThe family found a bruise you didn't chart: what to write next
- The doses are charted but the pain isn't movingDoses given, pain not moving: chart the pattern, escalate it, accuse no one
- When the dose isn't there to giveCharting a dose that never showed up so it doesn't read like one you skipped
- When the patient walks out before dischargeAMA or elopement: what to chart when the bed is empty and the tubing is still on the pole
- Charting a PRN sedative for behaviorHow to chart a PRN sedative so it doesn't read like chemical restraint
- Sedated, and nothing on the MAR explains itUnexplained sedation: chart how they woke, how they breathed, and keep putting times on it
- The narcotic count is off at shift changeNarcotic count off at shift change: what to write, who signs, and why nobody leaves yet
- Override pull meaning: pulling a med before pharmacy verifiesOverride pulls: charting the order, the reason, the second check and pharmacy
- Charting each comfort care dose when the doses keep climbingComfort care PRN doses: chart the symptom, the order and the reassessment every time
- When the barcode scan fails and you give the med anywayWhat to chart when the barcode won't scan and you give the med anyway
- When the patient is not in the roomCharting a missing patient: last seen, searched, found, and every time in between
- The postpartum mood screen came back positive. now what goes in the chartCharting a positive postpartum mood screen so someone can actually act on it
- When the patient says the new med is making things worseCharting a patient's complaint about a new med so the record shows you acted
- Counting a student's controlled medication from drop-Off to last doseControlled meds at school: keeping the count from parent drop-off to the last tablet
- Your note and the call light log should tell the same storyCharting a late call light so your note matches the log the machine already kept
- Charting the patient who is getting closer to violenceHow to chart an escalating patient so the record shows who knew, and when
- Charting the care you did not get toWhat to write when the care didn't happen, so the box is neither blank nor a lie
- The tube came out while you were giving careCharting a trach, G-tube or drain that came out during a bath, turn or transfer
- The dose you gave two hours lateLate meds: chart the real time, the real reason, and who you told
- The monitor alarm you silenced and what the chart says about itSilenced alarms, the alarm history, and the note that has to match it minute by minute
- The treatment from yesterday that nobody didYesterday's TAR box is blank: what you chart now and what you never initial
- The controlled drip that is emptying faster than the pump saysWhen the fentanyl bag runs lower than the pump says, and what actually goes in the chart
- The alert you clicked pastOverride reasons that say what fired, who decided, and what you're watching
- Changing the bag on a fentanyl drip without losing countChanging a fentanyl drip bag and charting it so the count actually closes
- When a visitor changed the pump or touched the lineCharting a pump or line a visitor touched: found settings first, their story as theirs
- When the pump, vent, monitor or bed fails during carePump, vent, monitor or bed failure: what to chart before biomed takes it
- The last count on a student's leftover pillsClosing out a student's leftover controlled meds: the count, the witness, the zero
Orders, handoffs and other people24Verbal orders, handoff, police at the bedside, chaperones, a coworker who seems unsafe.
- Documenting a verbal order and the read-backVerbal orders, read-back lines, and the gap between heard and confirmed
- What a nursing handoff note has to includeWhat the next nurse needs from your handoff note
- Charting a patient's report of abuse by staffVerbatim words, clean observations, safety steps, and zero creative writing
- When police ask for patient informationHow to chart police requests without playing courthouse in scrubs
- Documenting a chaperone during intimate careChart chaperones like someone later will read every blank out loud
- When your assessment may become evidenceChart what you saw, heard, did, and handed off before the note gets subpoena energy
- When a coworker seems impairedA coworker seems impaired: write what you saw, when, and who you told
- When bias changes who gives careHow to chart biased care refusals without turning the note into a group chat
- When a coworker says she gave it but it's not chartedShe gave it, she didn't chart it: what goes in your note and what stays out
- The patient who came in with an officerCharting a patient in custody: whose words, whose cuffs, whose hold
- When someone else says yes for the patientCharting consent from a surrogate: who decided, on what authority, and the limits
- Charting the call to the family when a resident changesWho you called, when, what you said, and every call that rang out
- When the patient tells you what they didWhat to chart when a patient tells you something that sounds like a crime
- The fetal heart tracing you called the provider aboutCharting the provider call about a fetal heart tracing so it matches the strip
- What your witness signature on a consent form really saysWhat your witness signature on a consent form covers, and when to leave the line blank
- Entering a protocol order under a provider's name without making it look like theirsProtocol orders under a provider's name, charted so nobody mistakes them for theirs
- Charting an off-label prescription so the reasoning showsOff-label prescriptions: charting the why, the alternatives, and the patient's yes
- When the patient is someone you knowWhen the name on the board is your aunt: handoff, charting, and staying off the audit
- Giving a med to someone else's patientCovering a coworker's med: your login, your note, her name in it
- The swab the lab asked for that nobody orderedThe lab asked for a swab, nobody ordered it, and your note is the only witness
- Charting care the parent gave during your shiftCharting the feeds, suctioning, and meds a parent did on your shift
- Charting the phone call and the portal messagePhone calls and portal messages: what to chart so your advice actually exists
- When the family tells you what they saw another staff member doCharting what the family saw a coworker do, without convicting anyone in the chart
- Charting care that changed because of a surge policyCharting care a surge policy changed, so the gap reads as policy
Fixing a note, and who sees it14Correcting a note you signed, the audit trail, co-signing, charting under the wrong login.
- How to correct a nursing note you already signedSigned it, then saw the wrong arm: corrections, addenda and late entries that hold up
- What the EHR audit trail shows about your chartingLate entries, wrong charts, and the history behind the signed note
- How to chart something you are not sure aboutChart unfamiliar findings without turning uncertainty into an unsupported fact
- What to do when an order looks wrongWhen the physician disagrees: chart the concern, the response, and the care
- Nursing chain of command: how to document itEscalation notes that go beyond “charge aware”
- Keeping your own notes, texts and screenshotsPersonal notes, screenshots, and the paperwork after the paperwork
- What co-signing a nursing note actually meansWhat to do when your co-signature says more than you actually saw
- Charting when you know you are being watchedHow to chart when family is recording without writing a panic novel
- Charting the conversation after a medication errorChart the medication-error disclosure, not just that someone was notified
- When charting happened under the wrong loginHow to fix wrong-login charting without adding a second mess
- You charted on the wrong patientWrong-patient charting: strike it, re-enter it, tell whoever already acted on it
- The reason you type when you open a chart that is not yoursWhat to type in the break-the-glass box so the audit never needs you
- When the patient asks who else gets to see this recordPrivacy requests at the bedside: chart the ask, pass it on, promise nothing
- When the camera saw it tooCharting a fall or assault when a camera or virtual sitter caught it too
Your job, not the chart18Calling out, time off, write-ups, getting hurt at work, being named in a suit, leaving a job.
- Calling out sick as a nurse: what to say and what to keepoften openedHow to call out sick without handing management a blank form to weaponize
- Is a no-call no-show patient abandonment? What boards sayHow to chart a missed shift without adopting management’s favorite accusation
- Requesting time off as a nurse: getting the answer in writingHow to ask for PTO so the schedule cannot pretend it heard poetry
- FMLA for nurses: what to put in writing and what retaliation cases turn onFamily leave paperwork that survives staffing, portals, and selective amnesia
- Nurse named in a malpractice suit: what happens to your notes and what to do firstNamed in a lawsuit: the chart speaks for you, so leave the old notes alone
- Floating to another unit: what you can refuse and what to documentHow to document a float assignment without turning your note into a bonfire
- Unpaid meal breaks and off-the-clock work for nurses: what records winMissed lunch, auto-deducted pay, and the record that actually survives
- Nurse corrective action and write-ups: what to sign, what to add, what to keepHow to answer a write-up without turning the chart into HR confetti
- Writing a statement for a hospital investigation: what belongs in itHow to write the statement without donating extra assumptions
- Calling out for a sick child: FMLA, what to say, and what to keepCalling out for a sick kid and still having a record when the attendance meeting comes
- Resigning as a nurse: notice, what to put in writing, what happens afterHow to quit in writing without handing anyone your grievances
- Job hunting as a nurse: non-competes, references and what you can take with youWhat you signed at hire, what stays behind, and how to quit on paper
- How to write a factual HR complaint without putting it in the patient chartSeparate charting from HR complaints before the system blends both into sludge
- Needlestick at work: what to do and what to write downNeedlestick charting without confessions, guesses, or shift-end archaeology
- A patient assaulted you: reporting and documenting itWhat to document after staff gets hit, without feeding the wrong machine
- Hurt at work: reporting an injury on duty and the deadlineWhat to document when your shift injury report is already late
- Risk management asked to talk: what that meeting isWhen risk says “just talk,” bring facts, not a courtroom monologue
- How to answer the discipline question on a nursing license applicationHow to answer the discipline question without turning it into a second, worse problem
What people open most
- Documenting a patient fall: the post-fall noteAfter a fall: chart what you saw and what you checked, and nothing you didn't
- How to document a patient refusal and AMARefusal notes: the decision, the discussion, and what happened next
- Calling out sick as a nurse: what to say and what to keepHow to call out sick without handing management a blank form to weaponize
When a new one goes up
One note a month: what was added, and which decision made it necessary. That is the whole list. Most months it is two or three articles.
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How these are put together
- Court decisions, not anecdotes. All 379 of them are listed in one place, with the court, the year and a link to the opinion. Cases come from CourtListener. 726 decisions were read to get to those 379. Most searches turn up something that looks relevant and is not; those are left out rather than counted. Every one is linked. Where we only had the search result and not the full opinion, the page says so instead of guessing.
- Forums are used for questions, never for facts. What people ask on r/nursing tells us what to write about. It does not tell us what happened in court.
- Nothing here is legal advice. It is how to write a note. Your board, your state and your facility policy are what bind you.
- It is added to over time. New topics come from what nurses ask, and each one goes through the same checks before it goes up.
- All of it is also published as data. The rewrites, the wording to avoid and every decision behind them are available as a corpus you can download, and as a server your own assistant can call. It takes no patient information and stores nothing.
- This section counts visits. These pages, and only these, load Google Analytics, so we can tell whether anyone reads them. It sets a cookie. The shift calculator and the contract decoder deliberately do not: what you type there never leaves your browser, and that has not changed.