shift is wild

How a note is read

Copied notes and why they stop meaning anything

Keep reused wording tied to what you actually assessed, with examples of what to chart and what to check before signing.

6 min read built on 6 full opinions updated 2026-09-12

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

Nick reacting to this topic

If you carry yesterday’s findings into today’s assessment without checking them, they read as something you found today. The next clinician can’t tell what you actually assessed.

The short version

  • Assess first. Only reuse text if your organization allows it. Verify every finding you carry forward.
  • Make the assessment time clear. A new note date does not make yesterday’s exam current.
  • Not assessed is not normal. Document what you couldn’t assess and why.
  • Show what happened: current findings, care actually provided, and the patient’s response.

What goes wrong

The mistake usually starts the same way: you copy the last assessment, update the obvious changes, and assume the rest is still right.

Now you’re working from the old note, not the patient. You update the pain score but miss the Foley that was removed. You describe new crackles in the narrative but leave clear breath sounds in the copied assessment. Or you keep a normal skin finding for an area you didn’t inspect today.

That blurs three things:

  • Time: Did you find this now or yesterday?
  • Source: Did you observe it, did the patient report it, or did another clinician document it?
  • Scope: Did you reassess everything described, or just one part?

The findings can stay the same. If you reassessed the patient and found no change, the same wording may still be accurate. You don’t need fresh adjectives every four hours. You need a fresh assessment behind the words.

A template can remind you what to check. It can’t tell you what you found.

It is not hypothetical

United States v. Eskender Getachew: U.S. Court of Appeals for the Sixth Circuit, 2025. The court described identical examination notes at every appointment for each patient named in the indictment. It also described identical menstrual-cycle observations in notes for all the named male patients. The court said this evidence allowed an inference that the physician routinely failed to examine patients.

The court affirmed his conviction for unauthorized controlled-substance prescribing based on a broader record of evidence. It did not rule that copying text alone establishes a crime. The point here is narrower: repeating the exam language did not necessarily mean repeating the exam.

Sevan (Bjorklund) Cappuccilli v. David A. Carcieri, M.D., d/b/a Medical Office of David A. Carcieri, M.D.: Supreme Court of Rhode Island, 2017. The patient used several medical records to support her account of an ovarian-vein injury during surgery. A physician challenged the accuracy of some records and testified that some entries had been copied and pasted.

The court affirmed the judgment for the defendants. The criticism of copied entries came from a witness. It was not a blanket court finding that copied notes are false. The documentation question was whether the repeated statements accurately described what happened, not how many places they appeared.

What to write instead

These are sample nursing entries, not excerpts from actual patient charts. Each pair assumes the findings and actions in the right-hand entry actually occurred. They show focused documentation, not complete assessments or care plans.

as written

Changed lung findings<br>1200 — Lungs clear bilaterally. No respiratory complaints.

as it holds up

1200 — Fine crackles at bilateral posterior bases. Respirations 20/min, unlabored. SpO₂ 95% on room air. Denies shortness of breath. 1205 — Dr. Lee notified of new crackles.

as written

Findings really are unchanged<br>1200 — Neuro assessment unchanged.

as it holds up

1200 — Alert; oriented to person, place, time, and situation. Speech clear. Hand grips and bilateral ankle dorsiflexion equal. These findings are unchanged from my 0800 assessment.

as written

Yesterday’s pain relief is no longer current<br>1500 — Pain controlled with current regimen.

as it holds up

1500 — Reports incisional pain 6/10 at rest. Ordered PRN analgesic administered; see MAR. 1545 — Reports pain 2/10 at rest.

as written

An area was not assessed<br>0900 — Skin intact. No redness or breakdown.

as it holds up

0900 — Patient declined sacral skin inspection, reporting fatigue. Explained purpose of inspection; patient continued to decline. Sacral skin not assessed at this time.

as written

A device is no longer present<br>1000 — Foley patent, draining clear yellow urine.

as it holds up

1000 — Voided 250 mL clear yellow urine into urinal. Foley removal at 0630 documented in prior RN’s entry.

Here is what the revised entries do:

  • You say what you found. A normal finding is useful when it comes from an actual assessment.
  • You keep the scope clear. Documenting selected neurological findings does not claim you tested every neurological function.
  • You separate observation from history. You measured the void. The prior nurse documented Foley removal. The entry makes that difference clear.
  • You show what you don’t know. If you didn’t inspect an area, you don’t call it intact.

Before you sign, check the reused narrative against today’s flowsheet, current devices, and the care actually completed. If they contradict each other, resolve the discrepancy. Don’t leave both versions in place.

Already signed? Use your organization’s correction or addendum process. Don’t quietly replace the original. And documenting what you couldn’t assess does not take the place of needed follow-up care.

Words that do the damage

The wording itself is not always wrong. Carrying it forward without checking is the problem.

Wording Why it becomes unhelpful Replace with
WNLHides what was actually assessed.Relevant findings, such as respirations 16/min, unlabored; breath sounds clear bilaterally.
UnchangedDoes not identify the comparison or the scope.Current findings plus the assessment time used for comparison.
Denies painReads as a current patient report, even when copied from yesterday.The patient’s current pain report, including location and score when applicable.
Skin intactCan imply inspection of areas you did not examine.The areas inspected and findings; identify any area not assessed.
Tolerated wellDoes not describe the response to today’s intervention.What the patient reported or what you observed during and after the intervention.

What the guidance says

  • Check reused assessment text against your current assessment. Don’t carry old findings forward unchecked. (Nurse.org, VeroScribe)
  • Chart the findings, completed nursing care, and the patient’s response. A general status statement is not enough. (Montgomery College, SimpleNursing)

If you remember one thing

Today’s note needs today’s assessment. A new date is not enough.

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.

  • When I worked the cardiac care unit and charted q4h assessments I would copy and paste from my assessments and change where appropriate. Now I only have one assessment per shift and don’t copy from the previous nurse. ... Document your own assessment- not someone else’s.

    r/nursing on Reddit: Do you copy and paste your assessments? reddit

  • Or if the previous nurse charted clear lungs but the new nurse hears crackles, they’ll delete that and chart crackles. So if I ensure my charting is accurate…. I should be okay? ... Yes, you should be fine. As long as you are CONSISTENT and ACCURATE in how you chart. Also, if you find those abnormal

    Copying Charting : r/nursing reddit

  • hahaha they should give us a &quot;writing course&quot; longer than nursing clinicals LOL I loved how you said &quot;I don't know how to write this&quot;, my biggest problem every day, I keep inspiring myself on the way the last nurse did it ... I absolutely despise charting. We were recently a

    r/nursing on Reddit: I hate how documentation has taken priority over pt care reddit

  • What did their notes say every day? Sensation intact and can move all extremities. N/V and constipation for the first couple of days. What did their GI assessment say? WNL. Thankfully the nurses documented it. Did it change the care I was getting? No. I know I don’t need to explain the importance of

    r/nursing on Reddit: MDs inaccurate documentation 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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