Fixing a note, and who sees it

The reason you type when you open a chart that is not yours

The break-the-glass box is a note to an auditor you will meet in eight months. Write one they can match without calling you.

5 min read built on 0 cases updated 2026-10-15

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

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You float to another unit, cover a break, answer a rapid response, or open a chart flagged as restricted. Epic asks you why. Whatever you type in that box gets saved with your name, the time, and the workstation. Months later someone in the privacy office may read it next to the rest of the chart. Then they decide whether your access makes sense.

Key points

  • Lead with your role: covering RN, float RN, rapid response RN, charge RN, receiving RN.
  • Say what you were actually doing: assessing, giving a med, taking report, returning a call.
  • Add what ties you to the patient: room, unit, who you're covering for.
  • Make sure something in the chart or staffing record backs it up later (a note, a MAR entry, a flowsheet row, a float assignment).
  • Opened the wrong chart? Close it. Tell your manager or the privacy office the same shift. Don't make up a reason after the fact.

What to write

How people write it How it reads better
OtherCovering RN for [NAME] break relief, 4 West. Assessing pt rm 412, scheduled 1400 meds.
Patient careReceiving RN. Report from ED, pt transferring to 5 South bed 22.
Chart reviewRapid response RN responding to rm 318. Reviewing MAR, vitals, code status.
Continuity of careFloat RN assigned to pt rm 207 this shift per staffing. Initial assessment.
Asked to lookReturning pharmacy call re: med reconciliation, home meds list, per primary RN [NAME].
Checking labsCharge RN. Verifying critical K+ result called by lab at 0215, notifying primary RN [NAME].

Every line on the right answers the three things a reviewer checks. Who you are to this patient. What you were doing. Where they can find it confirmed.

Template

Break-the-glass reason field

[ROLE: Covering RN / Float RN / Rapid response RN / Charge RN / Receiving RN] for [PATIENT ROOM OR BED], [UNIT]. [TASK: assessment / scheduled meds / report / responding to call]. Covering for or per [NAME, ROLE].

Short chart note when the access produced no other documentation

[DATE] [TIME]. Accessed chart as [ROLE] on [UNIT] at request of [NAME, ROLE]. Reviewed [WHAT YOU REVIEWED, e.g. most recent BMP, MAR, code status]. [WHAT YOU DID WITH IT, e.g. Result of K+ 3.1 relayed to primary RN [NAME] at [TIME]]. No further action by this RN. [YOUR NAME, CREDENTIALS].

Message to manager or privacy office after opening a chart by mistake

To: [MANAGER NAME] / [PRIVACY OFFICE]
Subject: Chart opened in error, [DATE]

On [DATE] at approximately [TIME], while working on [UNIT], I opened the chart of [PATIENT NAME OR MRN] in error. I intended to open [WHAT YOU MEANT TO OPEN, e.g. the patient in bed 14B with a similar name]. I closed the chart once I saw it was the wrong patient. I viewed [WHAT WAS ON SCREEN, e.g. the summary tab only] and did not document, print, or share anything from it. I am reporting this so it can be noted on the access record.

[YOUR NAME, CREDENTIALS]
[EMPLOYEE ID]
[PHONE OR EXTENSION]

Words to avoid

Word or phrase Why it hurts Use instead
OtherTells the reviewer nothing; it gets pulled for follow-up by defaultYour role plus the task
Patient careTrue of every access, so it proves nothing about this oneThe specific care: assessment, med pass, report
Chart reviewSounds like reading for its own sakeWhy you needed it: verifying a result, preparing for transfer
Just checkingReads as curiosityWhat you were checking and for whom
Per requestLeaves the obvious question open: whose request?Per primary RN [NAME] or Per Dr. [NAME]
Covering (alone)Covering whom, where, when?Covering RN for [NAME], [UNIT], break relief

Patient care in the reason box, nothing charted

Most people pick the vaguest option in the dropdown (Other, Patient care, Chart review) and click through. In the moment that feels fine. You know why you were there.

The reviewer doesn't. An audit works by matching your access against your assignment and against what you documented. Patient care gives them nothing to match. If you weren't on that patient's care team that shift and you charted nothing, your access looks exactly like someone browsing out of curiosity. So the reviewer comes to ask you. By then you may not remember a Tuesday night from eight months ago.

The second version of the same problem: the reason is true, but nothing follows it. You broke the glass to check a lab for a covering colleague, told them the result verbally, and charted nothing. The log shows you opened the chart, read results, and left. Nothing shows the care you gave.

About the night shift worry in the Reddit threads: breaking the glass on your own assigned patient is the system working as designed. The prompt fires on everyone. It isn't an accusation. The reason box is your note to the auditor. Write one they can match.

Bottom line

Write the reason so a stranger could find you in the staffing record and the chart. Without asking you a single question.

Official guidance

  • The reason you type when you break the glass is saved as part of the access record, along with your relationship to the patient. (accountablehq.com, residencyadvisor.com)
  • Reviewers compare each access with your care team role and with what you documented. Access with no matching clinical documentation and no care relationship gets flagged first. (residencyadvisor.com, riskintelligence.ca)
  • Apart from your reason, the log records who opened the chart, when, which patient, and from which workstation or source. (accountablehq.com, learn.pcc.com)

What this rests on

No published decision turned up for this question. We looked, and the searches are in the record. So this article stands on published guidance and on how the question is asked on the floor, not on a court opinion. That is a weaker footing than the rest of the guide, and you should know it before you rely on it. The decisions behind the other articles are all in one place.

From nurses online

Quoted as written. Opinion, not a source.

  • I CANNOT STRESS THIS ENOUGH. Yes “breaking the glass” guarantees who accessed the chart will be audited but this process can be done for ANY CHART, protected by “break the glass” or not.

    r/nursing on Reddit: Neurotic Night Shift Thought: Why do I feel like an actual criminal a reddit

  • It’s called a “chart audit”. ... Maybe ask registration to make your chart restricted so whenever someone opens it, they have to "break the glass." ... Oh wow thanks for showing that! Is that on epic? I’ve never seen anything like that on cerner. Thanks ... This is Epic. It's been a w

    How do I prevent people from accessing my chart : r/nursing reddit

  • Hi, legal nurse here. Contact the compliance officer and/or patient advocate or patient liaison. Do this via email so you have a paper trail. Tell them you want to file a grievance because you believe one of their employees may have accessed your chart without your permission.

    Help - unauthorized chart access : r/nursing reddit

  • ... It has the option of "break the glass". You have to type your password and give a reason for accessing the chart. Although it doesn't prevent people from accessing the chart that shouldn't be accessing it. When the chart audit is done, there is little room for excuses of them

    [deleted by user] : r/nursing reddit

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Advice, not law.