shift is wild

What you chart every shift

The skin check at the start of your shift

When a bruise turns up mid-shift, someone will ask if it was there when you came on. Chart so you can answer in one sentence.

9 min read built on 6 full opinions updated 2026-09-30

Written by a med-surg RN, ten years, day shift. Why there is no name on it

Denise reacting to this topic

You take over a baby, a sedated patient, or a resident with dementia. Four hours later someone finds a bruise on a forearm. The first question anyone asks is whether it was there when you came on. If your chart has a timed, region-by-region skin check with your name on it, you can answer in one sentence. If it only says skin intact, nobody can tell.

The short version

  • Do the skin check at the start of the shift, before tasks pull you away. Chart the time you looked, not the time you typed.
  • Go region by region and write down what you found in each one, including where you found nothing. Don't write skin intact.
  • For every mark, record where it is (anatomical landmark), its size in cm, its color and shape, and whether the skin is open. Add the words present at start of shift.
  • Write down who was there: the off-going nurse, a parent, or a second RN if your unit does two-nurse checks.
  • If you find something later, chart it as a new entry with its own time, and include who you told and when. Don't go back and edit the start-of-shift note.

What goes wrong

The most common mistake is the global normal: Skin warm, dry, intact, clicked at 0800 and never touched again.

The reason it fails is simple. Someone reading your chart two years from now can't tell what you actually looked at. Did you turn the patient and check the back? Did you look under the hospital bracelet, the SpO2 probe, the diaper, the C-collar? Did you check the scalp? Intact only means nothing was open. A big purple bruise on the thigh is still intact skin. So when a bruise turns up at 1400, the 0800 note can't show it was absent, and it can't show it was present either. You did the work, but your note doesn't prove it.

The second mistake is timing. Say you check at 0715 and chart at 1030. The record says 1030. If a family member visited at 0900, that gap matters.

The third mistake is giving up on hard cases. A 93-year-old on anticoagulants may have a dozen bruises. Writing multiple bruises feels reasonable, but it leaves no way to tell a new bruise from an old one. Group them by region instead. There's an example below.

It is not hypothetical

State v. Kennedy, Ohio Court of Appeals, Eleventh District, 2022. Opinion A resident with severe dementia couldn't say what had happened to her. After a reported incident, the assistant director of nursing, a wound care nurse, did a skin assessment within about two hours. The opinion records: "Hosler did not observe any injury to the patient." Staff kept checking that day and the next, and "no surface signs of injury developed." The appeal turned on a separate evidence issue, not on the skin check. The case still shows how much depends on timed skin observations when the patient can't speak.

Woodland Nursing Operations, LLC v. Vaughn, Texas Court of Appeals, Second District (Fort Worth), 2022. Opinion A post-stroke resident was later found to have a new head bleed. The plaintiff's expert criticized the facility's records for several gaps, including a missing baseline evaluation. He wrote that he could reach his conclusion "because the nursing notes trail off and are poor, in breach of the standard of care." The court let the claim go forward. When there's no baseline, an outside expert fills the gap with his own reading.

Abshire v. Christus Health Southeast Texas, Texas Supreme Court, 2018. Opinion This one isn't about bruising. It's about a missed history of brittle bone disease. The point still applies. The expert report quoted in the opinion says: "Failure of the nursing staff to document a complete and accurate assessment resulted in a delay in proper medical care." The Supreme Court held that the report was enough for the claim against the hospital to proceed.

Cota v. Adirondack Medical Center, New York Appellate Division, Third Department, 2025. Opinion This case shows the other side: a negative finding that was charted. After a patient fell, the hospital's expert relied in part on "the absence of bruising or point tenderness upon examination of her back the next day." The court still found open factual questions, so the note didn't settle the case. But the negative finding was in the record where both sides could argue about it. That only happens when someone writes it down.

Russell Lee Maze v. State of Tennessee, Tennessee Court of Criminal Appeals, 2010. Opinion A five-week-old infant came in with bruising to the face and abdomen. On cross-examination, the defense pointed to errors in the ED physician's notes, "such as the failure to note bruising." Separately, the mother said she had noticed the facial bruising "three to four days earlier." That was a physician's note, not a nurse's. The problem is the same one this article is about: when did the mark first appear, and who wrote it down?

What to write instead

How it often gets charted How it holds up better
Skin warm, dry, intact.0715 full skin check, pt turned side to side with off-going RN J. Lopez present. Scalp, face, ears, neck, chest, abdomen, back, sacrum, buttocks, perineum, bilat arms/hands, bilat legs/feet inspected. No bruising, redness, swelling, or open areas found. Under ID band, SpO2 probe site, and ETT tape inspected: no marks.
Bruise on arm.L forearm, dorsal, 4 cm below elbow crease: purple-blue bruise 3 x 2 cm, oval, skin not broken, no swelling, no grimace on palpation. Present at start of shift, 0720. Noted in handoff by off-going RN.
Multiple bruises to extremities, old.Bilat forearms: 7 bruises, 1–4 cm, purple to yellow-green, none open. R lower leg: 2 bruises, 2 cm and 3 cm, purple, none open. Pt on apixaban per MAR. All present at start of shift, 0730. Photo per unit policy: [yes/no].
Infant skin WNL.0705 infant undressed fully, diaper removed. Scalp, fontanelle, face, ears (front and behind), mouth/frenulum, neck folds, trunk, back, buttocks, genitals, arms, hands, legs, feet inspected. Mongolian spots over sacrum, 6 x 4 cm, blue-gray, flat, as charted at admission. No other marks. Mother present at bedside.
Pt agitated, skin assessment deferred.0715 pt pulling away, striking out. Face, arms, hands, and lower legs inspected: no marks. Back, sacrum, and thighs not inspected. Reattempted 0840 with CNA R. Patel assisting: back, sacrum, thighs inspected, no marks.
New bruise noted.1410 during repositioning, new bruise found R upper arm, lateral, 5 cm above elbow: red-purple, 4 x 3 cm, not present on 0715 check. Pt unable to describe. Charge RN M. Okafor notified 1415, provider Dr. A. Singh notified 1420.

These examples work because of a few habits:

  • Name what you looked under: tape, devices, restraints, diapers, compression stockings, and the skin around casts. People skip these spots.
  • Say what you couldn't check. If you chart a partial exam as partial, it's honest and useful. If you chart it as complete, it isn't.
  • Describe, don't diagnose. Chart color, size, and shape. Dating a bruise, deciding its cause, and staging a wound are for your facility's process and the provider. If you're weighing pressure injury against skin failure, describe what you see and follow your unit's pathway.
  • Say what the patient did. When a patient can't talk, their pain report is a grimace, pulling away, or a change in crying when you press. Grimaced and withdrew on light palpation gives a reader something to use. Tender doesn't.

Words that do the damage

Word or phrase Why it hurts Use instead
skin intactOnly means nothing is open. A closed bruise counts as intact.List the regions checked and what you found in each
WNL / within normal limitsDoesn't say whose normal, or what you looked atThe specific findings, including negatives
no bruising notedDoesn't show you looked. Noticing isn't examining.no bruising on inspection of [regions]
multiple bruisesCan't be compared later, so a new one gets lost in the listCount, size range, and color, grouped by region
old bruise / new bruiseDating a bruise by color is unreliable, and it isn't a nursing callColor and size, plus present at start of shift or not present on [TIME] check
appears to beSounds unsure but doesn't say whyState what you saw. If you're unsure, say why: lighting poor, recheck at [TIME]
no new skin issuesNew compared with what? The reader can't tell.unchanged from [TIME] check: [findings]
tolerated wellTells a reader nothing when the patient can't speakThe behavior you saw: lay still, no grimace, HR 88 to 90

What the guidance says

  • A skin assessment means looking and touching. Inspect for color and lesions, then palpate for temperature, texture, and turgor. (NCBI Nursing Skills, Lecturio)
  • If the patient can't report symptoms, their reactions take the place of words. Watch facial expression, breathing, and response to touch while you examine. (nurse.com, Medbridge)
  • Check the skin at and under devices like oxygen tubing and IV sites. Chart any redness, swelling, or breakdown at those sites specifically. (SimpleNursing, NurseChartingPro)

Copy this

1. Start-of-shift skin check, no findings

`` [DATE] [TIME OF EXAM] Start-of-shift skin check. [YOUR NAME, CREDENTIALS]. Present: [OFF-GOING RN NAME / SECOND RN NAME / FAMILY MEMBER AND RELATIONSHIP / NONE]. Patient [awake / asleep / sedated, RASS [SCORE]], position during exam: [SUPINE / TURNED L AND R]. Regions inspected: scalp, face, ears (front and behind), neck, chest, abdomen, back, sacrum/coccyx, buttocks, perineum/groin, bilateral arms and hands, bilateral legs and feet[, INFANT: fontanelle, mouth/frenulum, skin folds]. Under devices inspected: [ID BAND / SpO2 PROBE / ETT OR TRACH TIES / IV SITES / DIAPER / RESTRAINTS / STOCKINGS]. Findings: no bruising, redness, swelling, or open areas found in any region inspected. Palpation: no grimace, withdrawal, or change in crying/vitals on light palpation. Regions not inspected and reason: [NONE / REGION, REASON, PLANNED RECHECK TIME]. ``

2. Start-of-shift skin check, with findings

``` [DATE] [TIME OF EXAM] Start-of-shift skin check. [YOUR NAME, CREDENTIALS]. Present: [NAMES AND ROLES]. Patient [awake / asleep / sedated], position during exam: [POSITION]. Regions inspected: [LIST AS ABOVE]. Findings, all present at start of shift:

  1. [SIDE AND REGION, LANDMARK AND DISTANCE]: [COLOR] [SHAPE] mark, [LENGTH] x [WIDTH] cm, skin [not broken / open], swelling [yes / no], response to light palpation: [NO REACTION / GRIMACE / WITHDRAWAL].
  2. [SAME FORMAT].

[If many: [REGION]: [NUMBER] bruises, [SMALLEST]–[LARGEST] cm, [COLOR RANGE], none open.] Findings [match / differ from] handoff report and prior entry dated [DATE] [TIME]. Relevant context from chart: [ANTICOAGULANT / PLATELET COUNT / RECENT PROCEDURE / BIRTHMARKS CHARTED AT ADMISSION / NONE]. Photo per facility policy: [TAKEN, STORED IN [LOCATION] / NOT TAKEN]. All other regions inspected: no marks found. Regions not inspected and reason: [NONE / REGION, REASON, PLANNED RECHECK TIME]. ```

3. New finding later in the shift

`` [DATE] [TIME FOUND] New skin finding. [YOUR NAME, CREDENTIALS]. Found during: [REPOSITIONING / BATH / DIAPER CHANGE / DRESSING CHANGE / OTHER]. Location: [SIDE AND REGION, LANDMARK AND DISTANCE]. Description: [COLOR] [SHAPE] mark, [LENGTH] x [WIDTH] cm, skin [not broken / open], swelling [yes / no], response to light palpation: [NO REACTION / GRIMACE / WITHDRAWAL]. This area was inspected at [TIME OF START-OF-SHIFT CHECK] and no mark was present at that time. Between [START TIME] and [TIME FOUND], patient was [IN BED / IN CHAIR / OFF UNIT FOR [PROCEDURE] / WITH VISITORS]. Devices or equipment in contact with this area: [NONE / DESCRIBE]. Patient response: [BEHAVIOR OBSERVED; VITALS IF CHECKED]. Notified: [CHARGE RN NAME] at [TIME]; [PROVIDER NAME] at [TIME]; [OTHERS PER POLICY] at [TIME]. Orders or actions: [WHAT WAS ORDERED OR DONE]. Photo per facility policy: [TAKEN, STORED IN [LOCATION] / NOT TAKEN]. Recheck planned: [TIME]. ``

If you remember one thing

Write down when you looked, who looked with you, and every region where you found nothing. A later bruise will be compared against your note.

Read the decisions yourself

Every case below is a published decision on CourtListener. Open them. Nothing on this page asks you to take our word for what a court said — and where we only had the search result rather than the full opinion, it says so.

All the decisions behind this guide, in one page — searchable by court, year, or what happened.

What people say on the floor

Nurses talking to each other about this, quoted as they wrote it. This is opinion, not a source. It is here because it shows what the argument actually is — the rules above come from the decisions and the published guidance, not from these threads.

  • I was almost (has my union involved)written up today for staging a wound an unstageable when it was considered “skin failure”. The patient had been admitted for 14 days and apparently came in with the wound that progressed. Today was my first shift with the patient so i assessed documented the wound

    r/nursing on Reddit: Skin Failure vs. Pressure Injury reddit

  • I think that’s absolutely fine for documenting a shift assessment on skin. Not a head to toe skin assessment. If your facility doesn’t require it, that’s fine for you. Mine requires 2 nurses or a nurse and tech do a head to toe skin assessment at every admission and transfer and it needs to be docum

    r/nursing on Reddit: Skin assessment consent reddit

  • Bruises are intact because there’s no opened area. ... It depends on the context. In the ED skin assessment for an ambulatory patient, we document only open wounds or injuries relevant to the presenting complaint. In the skin assessment for an admission, we include anything that could be a traumatic

    r/nursing on Reddit: Skin Assessment reddit

  • But everywhere else I’ve always done head to toes on all my patients. It takes less than 5 minutes. ... One nurse got fired for documenting ao4, follows directions, understands rba to their upcoming surgery. This lady had dementia, nonverbal, and was recently intubated.

    r/nursing on Reddit: Does nurses really not do assessments? reddit

What everyone else says

Guidance from professional bodies, insurers and other people who write about this. Useful, but it is advice, not law — that part is above.

How would you chart it?

This is the part we cannot research. If you have a way of writing this that has held up — put it here. No account, no name needed. Nothing that could identify a patient: no room numbers, no dates of birth, no MRNs. Use placeholders, the example still works.

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