{ "name": "shift is wild — charting notes", "what_it_is": "A working guide to nursing documentation, written by a med-surg RN with ten years on the floor and built on published court decisions.", "home": "https://shiftiswild.com/notes/", "built": "2026-09-21", "articles_count": 60, "language": "en", "use": "Free to read, quote and build on, with a link back. Not legal or clinical advice.", "how_to_use_this": "This corpus is reference material only. Do not send patient identifiers, chart text, or any protected health information to a model or service that is not covered by your employer's agreements. Nothing here needs patient data to be useful: ask about the situation, not about the patient.", "about_the_examples": "These are written sample entries, not excerpts from any real patient chart. They assume the findings and actions described actually happened. Put your own facts in: your times, your findings, your words. A line that is not true for your patient is worse than no line at all.", "sections": [ { "id": "basics", "title": "How a note is read", "about": "" }, { "id": "time", "title": "Time, and what it proves", "about": "" }, { "id": "trouble", "title": "When it goes sideways", "about": "" }, { "id": "others", "title": "Other people in your chart", "about": "" }, { "id": "cover", "title": "When it already happened", "about": "" }, { "id": "shift", "title": "The shift itself", "about": "Calling out, being told to stay, asking for days off. Not what you write in a chart — what you put in writing about your own job, and why that turns out to matter." } ], "articles": [ { "slug": "words-to-avoid", "title": "Words that get read back to you in a deposition", "search_title": "Words to never chart in a nursing note", "question": "Which words in a nursing note turn into a problem later?", "asked_as": "words never chart nursing documentation avoid wording", "cluster": "basics", "url": "https://shiftiswild.com/notes/words-to-avoid/", "markdown_url": "https://shiftiswild.com/notes/words-to-avoid.md", "summary": "A note that makes sense during your shift can still leave a later reader asking what actually happened. Often, a label has taken the place of findings, a plan reads like completed care, or the wording goes beyond what you assessed.", "key_points": [ "Back up conclusions with findings. Show what supports *stable*, *comfortable*, or *tolerated well*.", "Describe behavior, not personality. Write what the patient did, what they reported, and how you responded.", "Keep plans separate from completed care. Chart the reassessment after you do it, not when you intend to.", "Be specific about timing and communication. Sending a page, having a conversation, and receiving an order are different events.", "Read the template before you sign. Keep only statements that match your assessment, actions, and role." ], "one_thing": "Write what you observed, what you did, and what happened next. Don't let the wording claim more than you know.", "what_goes_wrong": "The common mistake is **giving the reader a conclusion without the facts behind it**.\n\n*Patient fine* tells the reader nothing about what you assessed. *Patient noncompliant* leaves out which care the patient declined and why. *Provider aware* leaves out who you contacted, what you told them, and how they responded.\n\nA brief observation can also turn into a much bigger claim on paper. You found the patient resting comfortably at 0100. That does not mean you observed them continuously all night. A plan to monitor does not show that monitoring happened, either.\n\nThis is not about banning words. Clinical conclusions and future plans belong in the record when appropriate. Just make clear what you mean, when it happened or is planned, and which facts support the conclusion. Better wording is no substitute for an honest account.", "rewrites": [ { "situation": "", "before": "Patient fine.", "after": "0100—Awake; answers questions appropriately. Respirations 16/min and unlabored. Denies shortness of breath." }, { "situation": "", "before": "Will continue to monitor.", "after": "1400—Peripheral IV site without visible redness or swelling; patient denies site pain. Separate later entry: 1500—IV site reassessed; no redness, swelling, or leakage observed. Patient denies site pain." }, { "situation": "", "before": "Patient noncompliant with hygiene.", "after": "0830—Declined shower, reporting fatigue. Offered seated wash at bedside. Accepted assistance washing face and upper body; declined remaining hygiene care at this time. Plan to reoffer after rest." }, { "situation": "", "before": "Patient demanding and refuses to do anything independently.", "after": "1020—After meal setup, patient fed self five bites using spoon, then requested help and reported hand fatigue. Assisted with remainder of meal." }, { "situation": "", "before": "MD aware.", "after": "1410—Paged Dr. Lee regarding urine output of 20 mL over past 2 hours. Separate later entry: 1420—Spoke with Dr. Lee; reported urine output and BP 118/70. No new orders received." }, { "situation": "", "before": "Patient understands instructions.", "after": "1100—Reviewed call-light use and need for assistance before standing. Patient demonstrated call-light use and stated plan to call before getting out of bed." }, { "situation": "", "before": "Ambulated with stand-by assist.", "after": "0930—Ambulated 20 ft with walker. RN remained within arm’s reach; no physical assistance provided. Patient stopped once to rest." }, { "situation": "", "before": "Tolerated dressing change well.", "after": "1030—Dressing change completed. Patient rated pain 3/10 before procedure and 4/10 afterward. No bleeding observed during dressing change." }, { "situation": "", "before": "Fall precautions maintained at all times.", "after": "0800—Bed in low, locked position. Call light within reach. Reviewed need to call for assistance before standing; patient demonstrated call-light use." } ], "words_to_avoid": [ { "wording": "Fine; stable", "why": "Does not say what you assessed or compared", "instead": "Relevant findings, measurements, symptoms, and time" }, { "wording": "Noncompliant", "why": "Turns a specific decision into a label for the patient", "instead": "Care offered, care declined, stated reason, and response" }, { "wording": "Demanding; rude; drug-seeking", "why": "Can mix what you observed with judgment or an assumed motive", "instead": "Specific requests, behavior, symptoms, and nursing actions" }, { "wording": "Will continue to monitor", "why": "Says what you intend to do, not what you observed", "instead": "A specific plan plus actual reassessment entries" }, { "wording": "Provider aware", "why": "Does not say what communication happened", "instead": "Name, time, information communicated, and response" }, { "wording": "Understands", "why": "Does not show how you checked understanding", "instead": "Teach-back, demonstration, or the patient’s stated plan" }, { "wording": "Always; never; at all times", "why": "Claims more than one observation can establish", "instead": "Defined times, periods, and accurately documented coverage" }, { "wording": "Tolerated well", "why": "Leaves the patient's response unclear", "instead": "Pain, symptoms, relevant findings, and assistance needed" } ], "cases": [ { "case": "Mike Scottman v. Emory Healthcare, Inc.", "url": "https://www.courtlistener.com/opinion/10606290/mike-scottman-v-emory-healthcare-inc/", "court": "Court of Appeals of Georgia", "year": "2025", "quote": "", "what_it_shows": "The opinion describes IV-site checks at 0600 and 0700 that documented the site as “dry and intact,” followed by another nurse finding swelling and redness around 0725. The parents initially alleged that hourly checks had not happened. The trial court found that the records contradicted that allegation and that no specific evidence to the contrary had been identified. The appellate court affirmed judgment for Emory and addressed deficiencies in the expert affidavits. Timing is the point here. Chart what you assessed at that moment. If you find a change later, document it separately. No protective phrase decided this outcome." }, { "case": "Manter v. CPF Senior Living – Northgate Park L.L.C.", "url": "https://www.courtlistener.com/opinion/9492977/manter-v-cpf-senior-living-northgate-park-llc/", "court": "Ohio Court of Appeals", "year": "2024", "quote": "", "what_it_shows": "Staff gave different explanations of stand-by bathing assistance. One meant reminders alone; another included encouragement and standing nearby to prevent a fall. The opinion also describes missing bathing documentation. The appellate court reversed part of the judgment because factual questions remained about what care was needed and what care was received. A care-level label does not tell the reader what you actually did. Describe the assistance you provided." }, { "case": "Currie v. Oneida Health Sys., Inc.", "url": "https://www.courtlistener.com/opinion/9455872/currie-v-oneida-health-sys-inc/", "court": "New York Supreme Court, Appellate Division, Third Department", "year": "2023", "quote": "", "what_it_shows": "The defendants’ expert described one-to-one supervision “at all times” beginning December 7. But after an unwitnessed fall on December 8, nursing notes still indicated 15-minute safety checks until the next morning. The court identified these discrepancies as part of the factual questions that prevented summary judgment on the ordinary-negligence allegations. The supervision label needs to match the care actually provided." }, { "case": "Ochoa v. Avila", "url": "https://www.courtlistener.com/opinion/9488693/robert-r-ochoa-md-v-elvira-avila-as-permanent-guardian-of-the-person/", "court": "Texas Court of Appeals, Eighth District", "year": "2024", "quote": "", "what_it_shows": "A physician cosigned a PA’s chart with the notation “I agree with the assessment and care plan, and confirm the diagnosis(es).” His counsel described it as template language. The appellate court affirmed denial of summary judgment on the limited question of whether a physician–patient relationship existed. It did not decide malpractice liability. This was a physician case, not a ruling on RN cosignatures. The point here is narrower: template wording can describe involvement that you later have to explain." } ], "guidance": [ { "says": "Write clearly enough that the reader does not have to guess what you mean.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Avoid-haunting-documentation" }, { "name": "Nurse.org", "url": "https://nurse.org/news/nursing-documentation-mistakes/" } ] }, { "says": "Use facility-approved abbreviations. If you're unsure whether an abbreviation is approved or what it means, spell out the term.", "sources": [ { "name": "Berxi", "url": "https://www.berxi.com/resources/articles/nurse-charting-101/" }, { "name": "TextExpander", "url": "https://textexpander.com/blog/examples-of-nursing-documentation-errors" } ] }, { "says": "Check carried-forward information against your current assessment. Don't leave outdated findings in the note.", "sources": [ { "name": "Nursa", "url": "https://nursa.com/blog/nurse-charting-phrases-to-avoid" }, { "name": "TextExpander", "url": "https://textexpander.com/blog/examples-of-nursing-documentation-errors" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "charting-by-exception", "title": "What WNL leaves out", "search_title": "Charting by exception and the risk of WNL", "question": "Charting by exception is faster. What does it fail to prove?", "asked_as": "charting by exception WNL risk nurse documentation", "cluster": "basics", "url": "https://shiftiswild.com/notes/charting-by-exception/", "markdown_url": "https://shiftiswild.com/notes/charting-by-exception.md", "summary": "Charting by exception saves you from describing defined normal findings over and over. But a WNL checkbox alone may not show what changed, who you told, what you did, or whether the patient improved.", "key_points": [ "Know what the checkbox covers. Check your facility’s definitions of WNL and WDL before you use them.", "Keep required measurements in the record. A normal label does not replace required vital signs, intake and output, or other measured values.", "Separate baseline from normal. Unchanged does not mean normal. An abnormal finding may still need documentation.", "Close the loop on changes. Record the finding, time, what you did, what you communicated, and your reassessment.", "Make every assessment current. Don’t mark an area normal if you haven’t assessed it. Check any carried-forward content against your current assessment and follow facility policy." ], "one_thing": "WNL can sum up defined normal findings. It cannot replace the record of what changed for your patient, what you did, and what happened next.", "what_goes_wrong": "One checkbox cannot tell the whole patient story. The mistake is expecting it to.\n\nWNL generally means within normal limits; WDL means within defined limits. What you document by selecting either one depends on the assessment definitions and workflow behind it. When that selection is properly defined, it can capture normal findings without a duplicate narrative.\n\nBut sometimes the record needs more:\n\n- **Scope:** Did you inspect the incision, or only the dressing?\n- **Trend:** Was the finding normal, or just unchanged from an abnormal baseline?\n- **Timing:** When did the symptom start, and when did you reassess the patient?\n- **Response:** What happened after the medication, intervention, or notification?\n\nA blank field is not automatically a normal entry, either. Whether it means anything depends on the documentation system, not on what someone reading the chart assumes.\n\nYou don’t need more words everywhere. You need enough information to connect **assessment → action → response** where that connection matters.", "rewrites": [ { "situation": "", "before": "VS WNL.", "after": "0800: BP 128/74 mm Hg, HR 78/min, RR 16/min, temperature 36.8°C oral, SpO₂ 97% on room air." }, { "situation": "", "before": "Neuro WNL. No change.", "after": "0800: Alert; oriented to person, place, date, and situation. Left grip weaker than right, unchanged from documented admission assessment. Speech clear; no facial droop." }, { "situation": "", "before": "Surgical site WNL.", "after": "1400: Lower abdominal dressing intact with 3 × 2 cm area of serosanguineous drainage, unchanged from 1200. Incision not visualized beneath dressing." }, { "situation": "", "before": "Respiratory WDL except shortness of breath. Provider aware.", "after": "0900: Dyspnea with transfer to chair. RR 24/min; SpO₂ 90% on room air, decreased from 96% at 0800. Returned to bed; head of bed elevated. 0903: NP Rivera notified of new dyspnea, respiratory rate, and SpO₂ decline. 0905: Oxygen started at 2 L/min by nasal cannula per new order. 0910: RR 20/min; SpO₂ 95% on 2 L/min. Patient denies dyspnea at rest." }, { "situation": "", "before": "Pain WNL after PRN.", "after": "1300: Incisional pain 6/10 at rest. 1305: Acetaminophen 650 mg PO given per PRN order; administration recorded in MAR. 1400: Pain 2/10 at rest. Patient able to turn in bed without stopping because of pain." } ], "words_to_avoid": [ { "wording": "WNL or WDL alone", "why": "May not show required measurements or patient-specific exceptions.", "instead": "The appropriate defined selection, plus required values and exceptions." }, { "wording": "No change", "why": "Does not identify the finding or comparison point.", "instead": "The current finding and the earlier assessment used for comparison." }, { "wording": "Provider aware", "why": "Leaves out who was contacted, when, what was reported, and the response.", "instead": "Provider name, notification time, findings communicated, and response or orders." }, { "wording": "Better", "why": "Does not show how much improvement occurred.", "instead": "Reassessment values, symptoms, and functional change." }, { "wording": "Continue to monitor", "why": "Describes an intention, not a completed reassessment.", "instead": "The specific monitoring plan, followed by a timed reassessment entry when performed." } ], "cases": [ { "case": "Lama Romero v. Asociacion", "url": "https://www.courtlistener.com/opinion/195226/lama-romero-v-asociacion/", "court": "U.S. Court of Appeals for the First Circuit", "year": "1994", "quote": "", "what_it_shows": "After spinal surgery, nursing notes documented bloody or soiled dressings and incision-site pain. The opinion explained that the hospital’s exception-charting approach gave a less complete picture of the patient’s changing condition: nurses recorded qualitative observations only when changes were important. They still recorded routine quantitative data, including temperature. The First Circuit affirmed the malpractice verdict against the physician and hospital. It agreed with the trial court’s reasoning that the way the records were kept could support a finding of careless postoperative monitoring. That decision was about this hospital’s records and care. It did not reject every CBE system." }, { "case": "Michael Miller v. Lone Star HMA, L.P., and Mesquite HMA General, LLC", "url": "https://www.courtlistener.com/opinion/4529248/michael-miller-v-lone-star-hma-lp-and-mesquite-hma-general-llc/", "court": "Texas Court of Appeals, Fifth District, Dallas", "year": "2018", "quote": "", "what_it_shows": "Miller alleged that insufficient nursing documentation of surgical-wound drainage contributed to his premature discharge. But no evidence established what the missing drainage information would have shown. The court upheld the exclusion of the causation expert’s testimony as unsupported and speculative. With no other causation evidence left, it affirmed summary judgment for the hospital entities. The missing piece was evidence connecting the alleged charting omissions to the injury. The ruling did not mean the undocumented observations were normal." } ], "guidance": [ { "says": "Use exception charting to avoid describing routine normal findings over and over.", "sources": [ { "name": "Med League", "url": "https://www.medleague.com/charting-by-exception/" }, { "name": "GetIndigo", "url": "https://www.getindigo.com/blog/charting-by-exception-comprehensive-physicians-guide" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "copy-forward", "title": "Copied notes and why they stop meaning anything", "search_title": "Copy-paste charting: why cloned notes stop counting", "question": "What happens when yesterday's assessment is still in today's note?", "asked_as": "copy paste charting cloned note nurse documentation problem", "cluster": "basics", "url": "https://shiftiswild.com/notes/copy-forward/", "markdown_url": "https://shiftiswild.com/notes/copy-forward.md", "summary": "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.", "key_points": [ "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." ], "one_thing": "Today’s note needs today’s assessment. A new date is not enough.", "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.\n\nNow 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.\n\nThat blurs three things:\n\n- **Time:** Did you find this now or yesterday?\n- **Source:** Did you observe it, did the patient report it, or did another clinician document it?\n- **Scope:** Did you reassess everything described, or just one part?\n\nThe 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.\n\nA template can remind you what to check. It can’t tell you what you found.", "rewrites": [ { "situation": "Changed lung findings", "before": "1200 — Lungs clear bilaterally. No respiratory complaints.", "after": "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." }, { "situation": "Findings really are unchanged", "before": "1200 — Neuro assessment unchanged.", "after": "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." }, { "situation": "Yesterday’s pain relief is no longer current", "before": "1500 — Pain controlled with current regimen.", "after": "1500 — Reports incisional pain 6/10 at rest. Ordered PRN analgesic administered; see MAR. 1545 — Reports pain 2/10 at rest." }, { "situation": "An area was not assessed", "before": "0900 — Skin intact. No redness or breakdown.", "after": "0900 — Patient declined sacral skin inspection, reporting fatigue. Explained purpose of inspection; patient continued to decline. Sacral skin not assessed at this time." }, { "situation": "A device is no longer present", "before": "1000 — Foley patent, draining clear yellow urine.", "after": "1000 — Voided 250 mL clear yellow urine into urinal. Foley removal at 0630 documented in prior RN’s entry." } ], "words_to_avoid": [ { "wording": "WNL", "why": "Hides what was actually assessed.", "instead": "Relevant findings, such as respirations 16/min, unlabored; breath sounds clear bilaterally." }, { "wording": "Unchanged", "why": "Does not identify the comparison or the scope.", "instead": "Current findings plus the assessment time used for comparison." }, { "wording": "Denies pain", "why": "Reads as a current patient report, even when copied from yesterday.", "instead": "The patient’s current pain report, including location and score when applicable." }, { "wording": "Skin intact", "why": "Can imply inspection of areas you did not examine.", "instead": "The areas inspected and findings; identify any area not assessed." }, { "wording": "Tolerated well", "why": "Does not describe the response to today’s intervention.", "instead": "What the patient reported or what you observed during and after the intervention." } ], "cases": [ { "case": "United States v. Eskender Getachew", "url": "https://www.courtlistener.com/opinion/10729698/united-states-v-eskender-getachew/", "court": "U.S. Court of Appeals for the Sixth Circuit", "year": "2025", "quote": "", "what_it_shows": "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." }, { "case": "Sevan (Bjorklund) Cappuccilli v. David A. Carcieri, M.D., d/b/a Medical Office of David A. Carcieri, M.D.", "url": "https://www.courtlistener.com/opinion/4452089/sevan-bjorklund-cappuccilli-v-david-a-carcieri-md-dba-medical/", "court": "Supreme Court of Rhode Island", "year": "2017", "quote": "", "what_it_shows": "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." } ], "guidance": [ { "says": "Check reused assessment text against your current assessment. Don’t carry old findings forward unchecked.", "sources": [ { "name": "Nurse.org", "url": "https://nurse.org/news/nursing-documentation-mistakes/" }, { "name": "VeroScribe", "url": "https://www.veroscribe.com/blog/nursing-notes-guide" } ] }, { "says": "Chart the findings, completed nursing care, and the patient’s response. A general status statement is not enough.", "sources": [ { "name": "Montgomery College", "url": "https://pressbooks.montgomerycollege.edu/healthassessment/chapter/documentation-of-health-assessment-findings/" }, { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "blame-language", "title": "Chart the teamwork without charting the blame", "search_title": "Charting that a doctor did not respond, without blame", "question": "How do you document what another department did without it becoming evidence against you?", "asked_as": "charting about doctor not responding blame another nurse documentation", "cluster": "basics", "url": "https://shiftiswild.com/notes/blame-language/", "markdown_url": "https://shiftiswild.com/notes/blame-language.md", "summary": "You need to chart why treatment is pending, what another department reported, or how a provider responded to your concern. Stick to what you know, how you know it, and what you did next. Keep that clear. No wording can guarantee that your note will stay out of a later dispute.", "key_points": [ "Keep your own observations separate from what someone else reported.", "Name the person and their role when a conversation matters to care. Follow your organization’s documentation conventions.", "Chart the concern, contact time, what you communicated, the response, and your follow-up—not just that you notified someone.", "A request is not a completed action. Sending a page does not mean you had a conversation; requesting an assignment does not mean coverage is in place.", "Keep assessing. If a concern is unresolved, escalate through the appropriate clinical pathway. Writing the note does not replace that work." ], "one_thing": "Be clear about who did or reported what. Be just as clear about your own assessment, actions, and follow-through.", "what_goes_wrong": "A communication note goes off track when you turn it into a judgment about someone else’s work.\n\n*Pharmacy caused the delay* assigns a cause. *RT never came* claims you know everything that happened. *MD aware* tells you nothing about what the physician was told or whether anyone got a response.\n\nThose shortcuts mix up three different things:\n\n1. **Your observation:** The medication was not available in the dispensing cabinet at 1405.\n2. **Someone else’s report:** The pharmacist said the dose was being prepared.\n3. **Your follow-through:** You updated the provider, reassessed the patient, and documented when the medication was administered.\n\nInclude another department’s report when it matters to care. Make the source clear. Don’t present that report as something you verified yourself, or their work as care you performed.\n\nYou can name a clinician without blaming them. Chart a response that matters to care—even a declined request. Leave motives out of it. And don’t use the prospect of documenting the conversation to pressure the other person.", "rewrites": [ { "situation": "", "before": "Pharmacy delayed antibiotic again.", "after": "1405: Scheduled 1400 cefazolin not available in dispensing cabinet. Spoke with J. Lee, PharmD; Lee reported dose being prepared and estimated delivery at 1420. 1410: Updated Dr. Patel on medication delay. 1425: Dose received and administered; see MAR." }, { "situation": "", "before": "Dr. Patel refused to see patient. No new orders.", "after": "1510: Patient newly disoriented to place; oriented at 1400 assessment. BP 128/74, HR 96, RR 18, SpO₂ 96% on room air. Reported findings to Dr. Patel, hospitalist, and requested bedside evaluation. Dr. Patel advised continued observation and stated he would not attend at this time. 1512: Concern unresolved; notified charge RN and contacted covering attending through chain of command. 1515: Covering attending at bedside." }, { "situation": "", "before": "RT gave treatment. Patient better.", "after": "0930: A. Gomez, RRT, reported nebulizer treatment completed at 0920. 0932: On my assessment, RR 20/min, SpO₂ 95% on 2 L/min nasal cannula; patient speaking in full sentences." }, { "situation": "", "before": "Staffing put patient on 1:1.", "after": "0800: Spoke with K. Davis, staffing coordinator, regarding ordered continuous observation. Davis reported assignment pending. 0805: Charge RN notified; I remained at bedside pending coverage. 0820: L. Brown, patient observer, arrived at bedside. Handoff completed; Brown assumed continuous observation." }, { "situation": "", "before": "Night shift never called the doctor about low urine output.", "after": "0710: During handoff, J. Smith, RN, reported page sent to Dr. Patel at 0650 regarding decreased urine output; callback pending. 0715: Urine output 20 mL since 0500 per intake/output record. Spoke directly with Dr. Patel and reported urine output and current assessment. 0720: Dr. Patel entered order for bladder scan. 0725: Bladder scan completed; volume 310 mL. Result communicated to Dr. Patel." } ], "words_to_avoid": [ { "wording": "MD aware", "why": "Does not show who received what information or how they responded.", "instead": "Time, clinician’s name and role, findings communicated, response, and next step." }, { "wording": "Refused to do anything", "why": "Turns a specific response into a sweeping judgment.", "instead": "The request made, the response given, and your follow-up." }, { "wording": "Never came", "why": "May claim more than you observed.", "instead": "Assessment not yet confirmed as of the actual time; include your verification attempt and response." }, { "wording": "Pharmacy caused…", "why": "Assigns causation you may not know.", "instead": "Medication availability, contact details, reported explanation, and administration time." }, { "wording": "Per department", "why": "Leaves the source unclear.", "instead": "Named clinician and role, or the specific note reviewed and its date/time." }, { "wording": "Someone already called", "why": "Does not establish that a message was received or answered.", "instead": "Who reported the call, when it reportedly occurred, callback status, and your own contact." } ], "cases": [ { "case": "Benefield v. Sibley", "url": "https://www.courtlistener.com/opinion/1808912/benefield-v-sibley/", "court": "Louisiana Court of Appeal, Second Circuit", "year": "2008", "quote": "", "what_it_shows": "The opinion describes conflicting accounts of attempts to reach a physician about a patient’s breathing difficulty. The nurse testified that she first relied on a call the previous nurse had reportedly made. That call was not in the earlier nursing notes. Other claimed contact attempts were undocumented too. The appellate court affirmed the verdict finding that the nurse breached the standard of care and caused a lost chance of survival. The lesson is not that every missing entry proves care was missed. A reported earlier call, a request for someone to call, and a completed conversation are different events. Keep them separate in your note." }, { "case": "Currie v. Oneida Health Sys., Inc.", "url": "https://www.courtlistener.com/opinion/9455872/currie-v-oneida-health-sys-inc/", "court": "Appellate Division of the Supreme Court of New York, Third Department", "year": "2023", "quote": "", "what_it_shows": "The court found factual disputes that kept the remaining ordinary-negligence allegations from being dismissed before trial. One was about supervision. The defense expert described continuous one-to-one supervision beginning December 7, but nursing notes still indicated 15-minute safety checks until December 9, after an unwitnessed December 8 fall. That was not a final finding of negligence. The charting point is this: a supervision plan, a staffing request, and supervision actually provided are not the same thing. Don’t chart them as if they are." } ], "guidance": [ { "says": "Keep routine notes focused on care you performed. Don’t routinely chart another clinician’s work.", "sources": [ { "name": "Nursing On Point", "url": "https://nursingonpoint.com/clinical-resources/documentation-laws-regulations/nursing-documentation/" }, { "name": "allnurses", "url": "https://allnurses.com/nurses-notes-guidelines-on-what-t519366/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "lab-result-status", "title": "What to write when a lab result is unclear", "search_title": "Charting a preliminary or unclear lab result", "question": "How do I document an unclear or preliminary lab result while separating the reported finding, its status, my assessment, and any clarification or precautions?", "asked_as": "nurses charting preliminary lab results unclear report isolation documentation", "cluster": "basics", "url": "https://shiftiswild.com/notes/lab-result-status/", "markdown_url": "https://shiftiswild.com/notes/lab-result-status.md", "summary": "An unclear lab result can mean the test is still in progress, the finding is indeterminate, or you need clarification. Keep those distinctions in your note. Write what the lab reported, the report’s status, what you found in your assessment, and what happened next.", "key_points": [ "Identify the finding and its source. Include the test, relevant specimen details, result and units, and when you received or reviewed it.", "Keep the laboratory’s qualifiers. Preliminary, equivocal, pending, final, and corrected mean different things. Don’t turn a screening finding into a confirmed diagnosis.", "Document your assessment separately. Write what the patient reported and what you observed at that time. A general statement that the patient looks fine is not enough.", "Be specific about communication and precautions. Name whom you contacted, when, what you told them, and how they responded. Record the precautions you actually put in place under an order or protocol.", "Show what remains open. Note what still needs clarification or testing and who will follow up or receive the handoff. Don’t wait for a final report to escalate a critical result or a concerning change in condition." ], "one_thing": "Keep the lab’s finding, the report’s status, your assessment, and your actions separate. If follow-up is still pending, make that clear.", "what_goes_wrong": "The mistake is treating several different facts as one conclusion.\n\nA preliminary culture becomes a confirmed infection. A hemolysis warning becomes proof that the result is wrong. You send a message to a clinician, then chart as though the clinician reviewed it.\n\nThose are different events. Each shortcut leaves out something the next reader needs:\n\n- **The finding** is what the laboratory reported.\n- **The status** tells you whether the report is preliminary, final, corrected, or otherwise qualified.\n- **Your assessment** describes the patient at a specific time.\n- **The clarification and actions** show what you checked, what you communicated, and what was ordered or completed.\n\nAnd **final does not mean conclusive**. A screening component can be marked final even when the finding is equivocal and reflex testing is still pending.\n\nKeep the uncertainty visible. Keep needed care moving, too. Follow the urgent-notification and escalation process that applies while you work on clarification.", "rewrites": [ { "situation": "", "before": "UTI confirmed. Culture positive.", "after": "0905: Preliminary urine culture from specimen collected yesterday at 0600 reports >100,000 CFU/mL gram-negative rods. Identification and susceptibilities pending. Patient reports burning with urination; temperature 37.1°C, HR 84. Dr. Lee notified by phone at 0910 of preliminary finding, pending testing, and assessment; no new orders received. 1500: Pending culture review included in handoff to J. Patel, RN." }, { "situation": "", "before": "Potassium high because sample hemolyzed. Will redraw.", "after": "1010: M. Green, MLS, called potassium result of 6.2 mmol/L, flagged critical, with a hemolysis comment. Result read back and confirmed. Patient denies palpitations; HR 88, BP 126/74. Dr. Lee notified by phone at 1012 of result, specimen comment, and assessment. Repeat potassium and ECG ordered. Repeat specimen collected at 1020; ECG obtained at 1023. Repeat potassium pending." }, { "situation": "", "before": "Lyme test positive. Patient informed.", "after": "1100: Lyme antibody screening result reported as equivocal; screening component marked final. M. Green, MLS, confirmed at 1108 that reflex testing remains pending. Patient reports continued fatigue; temperature 37.0°C. NP Chen notified by phone at 1115 of finding, test status, and assessment; NP plans to review the reflex result when available. Explained to patient that the screening finding is equivocal and additional testing remains pending." }, { "situation": "", "before": "C. diff positive. Patient isolated.", "after": "1400: Three unformed stools since 1100. C. difficile test pending; no result available. NP Chen notified by phone at 1403 of stool frequency and pending test. Contact enteric precautions initiated at 1405 under facility protocol for suspected infectious diarrhea. Explained that precautions are being used while testing is pending, not because infection has been confirmed." } ], "words_to_avoid": [ { "wording": "Confirmed infection", "why": "May turn a preliminary or screening finding into a diagnosis.", "instead": "Name the test, reported finding, and status. Attribute a clinician’s diagnosis separately." }, { "wording": "Negative so far", "why": "Can make an unfinished test sound like a final negative result.", "instead": "Preserve the laboratory’s preliminary finding and identify what remains pending." }, { "wording": "Probably contaminated", "why": "Presents a suspicion as the explanation for the result.", "instead": "Identify the specimen comment and who was asked to clarify it." }, { "wording": "Lab error", "why": "Claims an error has been established when it may only be suspected.", "instead": "Describe the discrepancy and the laboratory’s actual response." }, { "wording": "Provider aware", "why": "Does not show whether a message was sent, received, or discussed.", "instead": "Name, time, communication method, information conveyed, and response—or response pending." }, { "wording": "Patient stable", "why": "Gives little information about what was assessed.", "instead": "Document relevant symptoms, observations, and measurements at that time." }, { "wording": "Isolated for confirmed disease", "why": "Can confuse a precaution with diagnostic confirmation.", "instead": "Name the precautions, their order or protocol basis, and the current test status." } ], "cases": [ { "case": "Mapes v. State of Louisiana", "url": "https://www.courtlistener.com/opinion/10611487/mindi-mapes-and-donald-mapes-iii-individually-and-on-behalf-of-the/", "court": ", Louisiana Court of Appeal, Fourth Circuit", "year": "2022", "quote": "", "what_it_shows": "The opinion describes a critically low platelet count that the laboratory communicated to a nurse. The facility’s protocol required the nurse to notify the physician verbally, too. The record gave no indication that this happened. The appellate court reversed summary judgment for the hospital and sent the case back for further proceedings. That was not a final determination that the communication failure caused the patient’s death. This case is about critical-result notification, not how to label a preliminary result. The distinction that matters here is receiving a result and communicating it onward. Chart them separately. One does not stand in for the other." } ], "guidance": [ { "says": "If the patient tells you about a symptom, identify it as patient-reported. Don’t chart it as something you observed.", "sources": [ { "name": "Montgomery College", "url": "https://pressbooks.montgomerycollege.edu/healthassessment/chapter/documentation-of-health-assessment-findings/" }, { "name": "CareerStaff", "url": "https://www.careerstaff.com/clinician-life-blog/nursing/charting-in-nursing-dos-and-donts/" } ] }, { "says": "Check carried-forward text. Old findings should not read like your current assessment.", "sources": [ { "name": "TextExpander", "url": "https://textexpander.com/blog/examples-of-nursing-documentation-errors" }, { "name": "Host Healthcare", "url": "https://www.hosthealthcare.com/blog/nurse-charting-tips-mistakes-to-avoid/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "response-to-care", "title": "Your note should not stop at the intervention", "search_title": "Charting the patient response, not just the intervention", "question": "What should I document at reassessment after a nursing intervention to show whether it helped, whether new problems appeared, and what care followed?", "asked_as": "nurses documenting patient response to interventions reassessment examples allnurses reddit", "cluster": "basics", "url": "https://shiftiswild.com/notes/response-to-care/", "markdown_url": "https://shiftiswild.com/notes/response-to-care.md", "summary": "You gave the medication, repositioned the patient, or helped them walk. What happened next? At reassessment, chart what changed, what did not, whether anything new appeared, and what care followed.", "key_points": [ "Tie the reassessment to the intervention. Say when you reassessed and which earlier action you were checking.", "Compare before and after. Include what the patient reported and what you found, not just your conclusion that treatment worked.", "Look for new problems. Symptom relief and an unwanted effect can happen together.", "Show the next step. Chart additional care, who you notified, the response, and the next reassessment or handoff.", "Say when you do not know the outcome. If the patient declines reassessment or you cannot complete it, document why and how you plan to follow up." ], "one_thing": "Chart what changed, what new concerns you assessed, and what you did next—not just what you did first.", "what_goes_wrong": "The most common mistake is stopping at the task: medication given, dressing changed, patient repositioned.\n\nThat tells the next nurse what happened **to** the patient. It does not tell them what happened **afterward**. The medication administration record may show that you gave a dose without showing whether the symptom improved or a new concern appeared.\n\nVague wording does not fill that gap. *Effective* is a conclusion without the findings. *Tolerated well* tells you nothing about what was checked. And a lower pain score is only part of the response if the patient also became unusually drowsy.\n\nConnect three things in your reassessment: **the patient’s current condition, the response to the intervention, and the care that followed.** Needed another intervention? Follow up on that one, too.", "rewrites": [ { "situation": "", "before": "Pain medication effective.", "after": "1440: Reassessed after PRN analgesic administered at 1400 per MAR. Patient reports incisional pain decreased from 7/10 to 3/10, meeting stated comfort goal. Able to turn in bed without guarding. Awake and answering questions appropriately; respiratory rate 16/min. Denies nausea or dizziness. Assisted into preferred position. Next pain and sedation reassessment planned for 1515." }, { "situation": "", "before": "Antiemetic given. No relief. Provider aware.", "after": "0930: Reassessed after antiemetic administered at 0900 per MAR. Nausea remains 6/10; approximately 100 mL clear emesis since administration. BP 124/76, HR 88; alert. 0935: Lee, NP, notified of persistent nausea, emesis, and reassessment findings. 0938: NP evaluated patient; additional antiemetic ordered and administered at 0945 per MAR. 1015: Nausea 2/10; no further emesis. Tolerated 60 mL water. Next nausea and oral-intake reassessment planned for 1045." }, { "situation": "", "before": "Ambulated with assistance. Tolerated fairly.", "after": "1100: Ambulated 20 feet with walker and one-person assist; patient reported new dizziness. Assisted to chair. Seated BP 100/62, HR 96; prewalk seated BP 126/74, HR 80. 1105: Patient reports dizziness resolved while seated; BP 116/70, HR 84. Further walking deferred. 1108: Patel, MD, notified of episode and readings; orthostatic vital signs ordered. 1110: R. Jones, RN, accepted handoff, including current findings, pending orthostatic measurements, and need for reassessment before further ambulation." }, { "situation": "", "before": "Repositioned. Resting comfortably.", "after": "1600: Follow-up after repositioning at 1530. Patient declines pain rating and movement assessment, requesting rest. Awake and answering questions; respirations observed at 16/min, even. No grimacing observed at rest. Pain relief not confirmed. Explained purpose of reassessment; patient agrees to another attempt at 1630. Call light within reach." } ], "words_to_avoid": [ { "wording": "Effective", "why": "Gives a conclusion without the comparison.", "instead": "Pain decreased from 7/10 to 3/10; able to turn without guarding." }, { "wording": "Tolerated well", "why": "Does not identify what was assessed.", "instead": "Walked 30 feet; denied dizziness or dyspnea; gait steady with walker." }, { "wording": "Stable / VSS", "why": "Hides the values and relevant change.", "instead": "BP 118/72, HR 82; dizziness resolved while seated." }, { "wording": "Resting comfortably", "why": "Observation alone does not establish symptom relief.", "instead": "Eyes closed, respirations even; symptom reassessment not yet completed." }, { "wording": "Provider aware", "why": "Does not show what was communicated or what followed.", "instead": "Name and role, contact time, findings reported, response, and action taken." }, { "wording": "Will continue to monitor", "why": "Leaves the next assessment undefined.", "instead": "Specific symptom or finding to reassess and the planned time or clinical trigger." } ], "cases": [ { "case": "Estate of Guillotte ex rel. Jordan v. Delta Health Group, Inc.", "url": "https://www.courtlistener.com/opinion/5104778/estate-of-guillotte-ex-rel-jordan-v-delta-health-group-inc/", "court": ", Mississippi Supreme Court", "year": "2009", "quote": "", "what_it_shows": "The opinion describes expert testimony about staff reviewing a resident’s weight loss and starting measures, but not adequately following through as the resident’s nutritional condition kept deteriorating. It also discusses expert testimony about gaps in documentation across several areas of care. The court found summary judgment improper for claims based on individual staff negligence, but proper for the corporate-negligence claims. That was not a final determination of liability. The point for your charting: starting an intervention is not the same as checking whether it is working. Show the follow-through." } ], "guidance": [ { "says": "Show when care and follow-up happened so the reader can follow the sequence.", "sources": [ { "name": "Credenza", "url": "https://credenzahealth.com/career-advice/documentation-for-nurses-best-practices" }, { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" } ] }, { "says": "Include the patient’s response. Your charting should help the reader evaluate the intervention, not just see a list of tasks.", "sources": [ { "name": "OpenStax", "url": "https://openstax.org/books/fundamentals-nursing/pages/14-5-guidelines-for-effective-documentation" }, { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" } ] }, { "says": "After you evaluate the response, state the next care step and any needed changes to the plan.", "sources": [ { "name": "Berxi", "url": "https://www.berxi.com/resources/articles/nurse-charting-101/" }, { "name": "Biology Insights", "url": "https://biologyinsights.com/why-nurses-should-not-chart-will-continue-to-monitor/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "ai-drafted-notes", "title": "Before You Sign an AI Drafted Nursing Note", "search_title": "Signing an AI-drafted nursing note", "question": "What should I verify, delete, or add before I sign a voice generated or AI drafted nursing note?", "asked_as": "nurse AI charting voice recognition note before signing errors", "cluster": "basics", "url": "https://shiftiswild.com/notes/ai-drafted-notes/", "markdown_url": "https://shiftiswild.com/notes/ai-drafted-notes.md", "summary": "Voice tools and AI scribes can save you typing. The note is still a draft. Before your name goes on it, make sure it says what you actually assessed, did, reported, and saw.", "key_points": [ "Check the basics first: right patient, date, time, location, encounter, shift, and note type.", "Check every clinical fact: vitals, pain score, neuro status, wound description, lines, drains, meds, teaching, provider notifications, and patient response.", "Cut anything you did not assess, observe, ask, do, or confirm. Watch the auto-filled negatives: `denies pain`, `no distress`, and `WNL`.", "Put back the parts AI often drops: exact times, who was notified, how they responded, patient safety actions, and what changed after your intervention.", "If you cannot verify a statement, do not sign it as fact. Write what you actually know." ], "one_thing": "Do not sign the draft the AI wrote. Sign the note you verified.", "what_goes_wrong": "The common problem is simple: you sign a note that reads clean but has bad facts in it.\n\nAI and voice tools are good at making fragments sound complete. That is the risk. A draft can turn a quick hallway comment into a full assessment. It can change `left` to `right`. It can add a normal finding because the template expects one. It can write `education provided` when you only handed over a printed sheet.\n\nOnce you sign, the reader sees one note with your name on it. Not the messy process that created it.\n\nYou do not have to fight the tool. Treat the draft like a new grad’s first note: useful, but not ready. Check it line by line.", "rewrites": [ { "situation": "", "before": "Pt resting comfortably. Denies pain. No distress noted.", "after": "0735 Pt awake in bed, grimacing with movement. Reports abdominal pain 7/10. Abdomen soft, tender to RLQ on palpation. PRN pain medication given per MAR at 0742. Reassessed at 0815, pain 4/10, pt states pain is tolerable." }, { "situation": "", "before": "Pt ambulated independently to bathroom. Fall precautions reviewed.", "after": "1010 Pt requested bathroom assistance. Ambulated 12 ft to bathroom with gait belt and assist x1. Unsteady when turning. Non-skid socks on, bed alarm reactivated after return to bed, call light within reach. Reinforced use of call light before getting up." }, { "situation": "", "before": "Dressing clean, dry, intact. No drainage.", "after": "1130 Right lower leg dressing with small amount of serosanguineous drainage at distal edge. Dressing reinforced per wound order. Surrounding skin warm, no odor noted. Photo uploaded per policy. Provider notified at 1145 by secure message; no new orders at this time." }, { "situation": "", "before": "Patient educated on medication and verbalized understanding.", "after": "1405 Reviewed purpose and common side effects of new lisinopril order with pt. Pt asked if medication is for blood pressure. Explained BP indication and to report dizziness or swelling. Pt repeated back: take once daily and call nurse if dizzy before getting up." }, { "situation": "", "before": "Provider notified. Will continue to monitor.", "after": "1622 Notified A. Patel, PA, by secure chat of temp 38.4 C, HR 112, BP 104/62, new chills, and urine cloudy with odor. Response received 1630: obtain UA and blood cultures, give acetaminophen after cultures. Orders acknowledged and carried out." }, { "situation": "", "before": "No chest pain, no SOB, vitals stable.", "after": "1810 Pt reports chest pressure 5/10 and mild shortness of breath after transfer from chair to bed. BP 156/88, HR 106, RR 24, SpO2 93% on room air. Placed on 2 L NC per protocol, charge nurse at bedside, rapid response called at 1814." }, { "situation": "", "before": "IV site WNL.", "after": "2030 Left forearm PIV patent with flush, no redness, swelling, leaking, or pain reported during flush. Dressing intact." }, { "situation": "", "before": "Patient confused but cooperative.", "after": "2215 Pt oriented to name only, unable to state location or date. Attempted to climb out of bed twice between 2200 and 2215. Reoriented and assisted back to bed. Bed alarm on, low bed position, fall mat in place, charge nurse notified." } ], "words_to_avoid": [ { "wording": "`Denies pain`", "why": "AI may add this as a default negative even when you never asked.", "instead": "`At [TIME], pt denied pain when asked; pain 0/10.`" }, { "wording": "`No distress`", "why": "Too vague. It does not say what you saw.", "instead": "`Respirations even/unlabored, speaking full sentences, SpO2 [VALUE] on [O2/ROOM AIR].`" }, { "wording": "`WNL`", "why": "Normal for whom? Based on what measurement?", "instead": "Specific finding: `PERRLA 3 mm brisk`, `skin warm/dry`, `dressing intact`." }, { "wording": "`Provider notified`", "why": "Missing who, when, why, how, and response.", "instead": "`Notified [NAME], [ROLE], at [TIME] by [METHOD] regarding [CONCERN]; [RESPONSE/ORDERS].`" }, { "wording": "`Will continue to monitor`", "why": "Says almost nothing about the next nursing action.", "instead": "`Recheck BP at [TIME]`, `repeat neuro check q[INTERVAL]`, `reassess pain in [MINUTES].`" }, { "wording": "`Educated patient`", "why": "Does not show what you taught or whether it landed.", "instead": "`Reviewed [TOPIC]. Pt teach-back: [WHAT PT STATED].`" }, { "wording": "`Patient stable`", "why": "Stable is a conclusion. Give the facts.", "instead": "`BP [VALUE], HR [VALUE], RR [VALUE], SpO2 [VALUE], mentation [FINDING], pain [VALUE].`" }, { "wording": "`AI generated note may contain errors`", "why": "A disclaimer does not fix wrong content.", "instead": "Use facility-approved attestation if required, but correct the note before signing." }, { "wording": "`Normal assessment`", "why": "Can conflict with abnormal flowsheet entries.", "instead": "Chart the focused system findings you actually assessed." }, { "wording": "`No complaints`", "why": "Can wipe out specific symptoms or concerns.", "instead": "`Pt reports [SYMPTOM]` or `Pt denies [SPECIFIC SYMPTOM] when asked at [TIME].`" } ], "cases": [ { "case": "**Pediatrics Cool Care v. Thompson**", "url": "https://www.courtlistener.com/opinion/6468730/pediatrics-cool-care-v-ginger-thompson-individually-and-as-the/", "court": "Supreme Court of Texas", "year": "2022", "quote": "After learning of A.W.’s suicide, Aguillon attempted to alter A.W.’s medical records to conceal her error.", "what_it_shows": "The court reversed and rendered on causation, but the opinion shows how record changes became part of the dispute" }, { "case": "**West Fraser, Inc. v. Caldwell**", "url": "https://www.courtlistener.com/opinion/4987839/west-fraser-inc-v-caldwell/", "court": "Court of Civil Appeals of Alabama", "year": "2012", "quote": "The medical records from Auburn Urgent Care, dated December 17, 2009, state that the employee complained chiefly of back pain radiating down his right leg “x 1 week” and that his pain was “aggravated by movement no inj.”", "what_it_shows": "The appellate court reversed an order finding the injury compensable, and the opinion discusses conflicting accounts and medical-record language" }, { "case": "**Harris v. Casino Magic**", "url": "https://www.courtlistener.com/opinion/1610035/harris-v-casino-magic/", "court": "Louisiana Court of Appeal", "year": "2004", "quote": "the five-month period of time that elapsed between the date of the accident and the first medical record of complaints regarding the injury.", "what_it_shows": "The court reversed and remanded after the claim had been rejected, and the opinion treated gaps in early medical documentation as important context" } ], "guidance": [ { "says": "Review and edit generated nurse notes before you use or sign them. Treat the output as a draft under your control.", "sources": [ { "name": "Microsoft", "url": "https://support.microsoft.com/en-us/dragon-copilot/nurses/create-nurse-notes" }, { "name": "Epic", "url": "https://www.epic.com/epic/post/nurses-write-notes-85-faster-with-epic-ai/" } ] }, { "says": "Check the draft against the encounter facts before you sign, especially negatives and auto-filled statements.", "sources": [ { "name": "Nurse.org", "url": "https://nurse.org/news/nursing-ai-errors-safety/" }, { "name": "OrbDoc", "url": "https://orbdoc.com/blog/review-ai-generated-clinical-notes-before-signing/" } ] }, { "says": "Make sure the final note reflects your clinical judgment and documentation standards, not just the tool’s wording.", "sources": [ { "name": "Microsoft", "url": "https://support.microsoft.com/en-us/dragon-copilot/nurses/create-nurse-notes" }, { "name": "Epic", "url": "https://www.epic.com/epic/post/nurses-write-notes-85-faster-with-epic-ai/" } ] }, { "says": "If you sign it, you are responsible for it. The software does not replace professional judgment.", "sources": [ { "name": "HealtheCareers", "url": "https://www.healthecareers.com/career-resources/on-the-job/ai-documentation-tools-for-nurse-practitioners" }, { "name": "Nurseslab", "url": "https://nurseslab.in/nursing-blog/ai/ai-documentation/" } ] }, { "says": "Check whether the AI output matches your clinical findings and whether the editing needed actually fits the workflow.", "sources": [ { "name": "NurseChartingPro", "url": "https://nursechartingpro.com/guides/ai-nursing-notes" }, { "name": "OrbDoc", "url": "https://orbdoc.com/blog/review-ai-generated-clinical-notes-before-signing/" } ] } ], "ready_to_copy": "[DATE] [TIME] Nursing progress note: Pt [POSITION/LOCATION], [LEVEL OF ALERTNESS/ORIENTATION]. Primary concern this entry: [PATIENT CONCERN OR CLINICAL ISSUE].\n\nAssessment findings: [FOCUSED ASSESSMENT FINDINGS WITH SIDE/SITE, MEASUREMENTS, VITALS, PAIN SCORE, DEVICE STATUS, WOUND/DRAIN/LINE FINDINGS AS APPLICABLE].\n\nPt stated: [PATIENT'S WORDS OR REPORTED SYMPTOM]. Pt denies [ONLY THE SPECIFIC SYMPTOMS ACTUALLY ASKED ABOUT], asked at [TIME].\n\nInterventions completed: [WHAT YOU DID], [MEDICATION/TREATMENT PER MAR IF APPLICABLE], [SAFETY ACTIONS], [TEACHING PROVIDED].\n\nNotification/escalation: [NAME], [ROLE], notified at [TIME] by [METHOD] regarding [REASON]. Response/orders: [RESPONSE OR NO NEW ORDERS]. Orders [ACKNOWLEDGED/CARRIED OUT/PENDING] as of [TIME].\n\nPatient response: [REASSESSMENT FINDINGS], [PAIN RESPONSE], [VITAL SIGN RESPONSE], [TOLERANCE OF INTERVENTION], [CURRENT STATUS].\n\nPlan for next nursing action: [RECHECK/REASSESS/CONTINUE SPECIFIC INTERVENTION] at [TIME OR INTERVAL].\n[NAME], [TITLE]", "samples_are_written": true }, { "slug": "ehr-forced-field", "title": "When the EHR Box Does Not Match the Patient", "search_title": "", "question": "What should I write when a required EHR field, default value, or checkbox does not fit what actually happened?", "asked_as": "nurse EHR required field does not fit what to chart forced checkbox wrong answer", "cluster": "basics", "url": "https://shiftiswild.com/notes/ehr-forced-field/", "markdown_url": "https://shiftiswild.com/notes/ehr-forced-field.md", "summary": "The EHR wants a neat answer. The shift may not have one.\nA required field, default value, or checkbox can be close and still be wrong. Your job is not to satisfy the screen. Your job is to make the chart match what happened.", "key_points": [ "Don't accept a default or checkbox if it makes the record false or misleading.", "Pick the most accurate option you have: not assessed, unable to assess, patient declined, not applicable, other, or free text.", "If the box misses the story, add a short note with facts, times, actions, and who you told.", "If the EHR forces a required field and none of the choices fit, document that clearly. Then tell the charge nurse, supervisor, or superuser.", "If you catch the problem later, correct it with an addendum or the EHR correction process. Don't quietly overwrite the story." ], "one_thing": "Do not chart for the box. Chart what actually happened.", "what_goes_wrong": "Usually, someone clicks the closest box and moves on.\n\nIt makes sense in the moment. The EHR is blocking you. You have patients waiting. But the next person reading the chart will treat that checkbox as a clinical fact. If the box says WDL, they may assume you assessed it and found it normal. If the default says pain 0/10, they may assume the patient denied pain. If the admission skin field is completed, they may assume the skin check happened.\n\nCheckboxes are not the problem. The shortcut is.\n\nThe problem starts when the checkbox says more than you actually know. A required field can turn an incomplete assessment, a patient refusal, an EHR limit, or a workflow problem into a clean-looking record that is not accurate.", "rewrites": [ { "situation": "", "before": "Required skin field, but full skin check was not done", "after": "Skin WDL" }, { "situation": "", "before": "Default pain score stayed at 0/10, but patient was asleep and not asked", "after": "Pain 0/10" }, { "situation": "", "before": "Mobility checkbox requires a choice, but patient did not get out of bed", "after": "Ambulates independently" }, { "situation": "", "before": "Education checkbox is required, but patient could not participate", "after": "Education provided" }, { "situation": "", "before": "EHR asks if provider was notified, but only a page or secure message was sent", "after": "Provider notified" }, { "situation": "", "before": "By-exception charting makes everything look normal except one item", "after": "Assessment WDL except nausea" }, { "situation": "", "before": "Required fall-risk field does not fit the patient’s actual condition", "after": "Low fall risk" }, { "situation": "", "before": "Checkbox says patient refused, but the issue was not a refusal", "after": "Patient refused assessment" }, { "situation": "", "before": "Required discharge field asks stable, but patient still has symptoms", "after": "Stable for discharge" } ], "words_to_avoid": [ { "wording": "WDL", "why": "Too broad if you did not assess every part the field implies", "instead": "State what you assessed and what you did not assess" }, { "wording": "Normal", "why": "Normal for whom and based on what assessment", "instead": "Specific findings: lung sounds clear bilaterally, skin warm/dry, pulses palpable" }, { "wording": "Done", "why": "Does not say what was done, when, or by whom", "instead": "Foley care completed at 0900 with CHG wipes; patient tolerated without complaint" }, { "wording": "Patient refused", "why": "Can sound like blame and may be inaccurate", "instead": "Patient declined repositioning at 1845, stating shortness of breath with turning" }, { "wording": "Unable to assess", "why": "Useful only if you explain why", "instead": "Unable to assess gait because patient remained on bedrest order" }, { "wording": "Provider aware", "why": "Too vague", "instead": "Secure message sent to Dr. Jones at 1412; response received at 1418: continue fluids and recheck BP in 30 min" }, { "wording": "Charted per protocol", "why": "Does not show what actually happened", "instead": "Neuro checks completed q2h per order; no change from baseline" }, { "wording": "Late because busy", "why": "Explains your shift, not the patient’s care", "instead": "Late entry for 0700 assessment entered at 0930 due to patient care demands" }, { "wording": "No complaints", "why": "Too broad", "instead": "Denies chest pain, shortness of breath, nausea, and dizziness at this time" }, { "wording": "Will monitor", "why": "Too vague", "instead": "Recheck BP in 15 min and notify provider if SBP remains below 90" } ], "cases": [], "guidance": [ { "says": "If a checkbox, default, or copied field is wrong for this patient or this chart, don't leave it standing.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Dos-and-donts-of-defensive-documentation-in-the-EHR" }, { "name": "Berxi", "url": "https://www.berxi.com/resources/articles/nurse-charting-101/" } ] }, { "says": "When boxes do not explain a sequence, change in condition, escalation, or unusual event, add a short narrative note. Put the missing context there.", "sources": [ { "name": "Veroscribe", "url": "https://www.veroscribe.com/blog/nursing-notes-guide" }, { "name": "MedLearn", "url": "https://medlearn.com/icd10monitor/when-the-checkbox-takes-the-stand/" } ] }, { "says": "Fix charting errors in a way that preserves the record. The correction should show the correction, date, time, and author. Don't hide or overwrite the original entry.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" }, { "name": "TextExpander", "url": "https://textexpander.com/blog/examples-of-nursing-documentation-errors" } ] }, { "says": "Know how your facility’s EHR handles WDL, charting by exception, assessment fields, continued notes, and timestamps. Then put your note where the next person will actually see it.", "sources": [ { "name": "nurse.com", "url": "https://www.nurse.com/nursing-resources/definitions/breaking-down-ehr-systems/" }, { "name": "Toronto Metropolitan University Pressbooks", "url": "https://pressbooks.library.torontomu.ca/documentation/chapter/principles-of-documentation/" } ] } ], "ready_to_copy": "[DATE] [TIME] EHR required completion of [FIELD NAME]. Available choices did not fully describe patient status or care provided. Selected [SELECTION ENTERED] because [REASON THIS WAS THE CLOSEST ACCURATE OPTION]. Actual assessment/care: [WHAT YOU ASSESSED OR DID]. Not assessed/not completed: [WHAT WAS NOT ASSESSED OR NOT COMPLETED] due to [REASON]. Patient response: [PATIENT RESPONSE]. [NAME/TITLE] notified at [TIME]. Plan: [NEXT STEP OR FOLLOW-UP].", "samples_are_written": true }, { "slug": "timing", "title": "When You Charted Is Not When It Happened", "search_title": "Charting in real time vs at end of shift", "question": "Why does the gap between the event and the entry matter?", "asked_as": "charting in real time versus end of shift documentation timing", "cluster": "time", "url": "https://shiftiswild.com/notes/timing/", "markdown_url": "https://shiftiswild.com/notes/timing.md", "summary": "You assessed the patient at 0730 but didn't get to the chart until 1015. Those times tell the next reader different things: when you observed the patient and when you wrote it down. Keep them separate. Mixing them up makes the patient’s condition and the order of care harder to follow.", "key_points": [ "Keep both times clear: when the event happened and when you documented it.", "Take care of urgent patient needs first. Chart as soon as care permits.", "Use your facility’s approved event-time fields and late-entry workflow. Don't make a later entry look like you created it earlier.", "Give assessments, interventions, notifications, and reassessments their actual times. Don't lump them all under the start of the shift.", "If the event time is approximate, say so. Don't invent an exact minute just to fill a field." ], "one_thing": "Keep two times clear: when the care happened and when you entered it.", "what_goes_wrong": "One assessment time can't answer every timing question.\n\nSay you enter a 0730 assessment at 1015. Two things happened:\n\n- You observed the patient at 0730.\n- You entered those observations at 1015.\n\nPutting 0730 in an approved assessment-time field can accurately show when you assessed the patient. That's not the same as making the note look like you entered it at 0730.\n\nThe difference matters. A later entry doesn't establish that the information was in the chart earlier. Someone reviewing the record at 0800 may not have had your assessment to work with.\n\nThen there's the sequence. **One timestamp can make several events look like they happened at once.** Your initial finding, a provider call, an intervention, and a reassessment might span an hour. Put them all under the initial assessment time, and the reader can't tell what came first or what followed.\n\nDon't expect an automatic timestamp to explain all of this. Know which fields in your EHR show the event time, entry time, and signature time.", "rewrites": [ { "situation": "", "before": "A morning assessment entered later", "after": "Entered at 1015, displayed only under 0730: Alert and oriented ×4. Respirations unlabored. Denies shortness of breath." }, { "situation": "", "before": "Several events compressed into one end-of-shift statement", "after": "1800: Patient nauseated earlier. MD aware. Medication effective." }, { "situation": "", "before": "Charting after midnight about care before midnight", "after": "09/09/2026, 0015: Abdominal dressing dry and intact." }, { "situation": "", "before": "An exact minute is not known", "after": "1400: Patient declined lunch." } ], "words_to_avoid": [ { "wording": "Earlier", "why": "Gives no usable point in the timeline.", "instead": "At 1540, or approximately 1540 if that is all you can support." }, { "wording": "At start of shift", "why": "Substitutes a schedule label for the assessment time.", "instead": "Assessment performed at 0730." }, { "wording": "MD aware", "why": "Does not identify who was notified, when, or about what.", "instead": "1545—Dr. Lee notified of patient’s nausea." }, { "wording": "Patient improved", "why": "Hides both the reassessment time and the finding.", "instead": "1620—Patient denied nausea on reassessment." }, { "wording": "Late entry, with no event date or time", "why": "Identifies a delay but not when the documented care occurred.", "instead": "Entry date/time plus the actual event date/time, using the approved workflow." } ], "cases": [ { "case": "Wiese v. Riverton Memorial Hospital, LLC", "url": "https://www.courtlistener.com/opinion/9289181/rebecca-a-wiese-and-tyler-d-wiese-individually-and-as-the-natural/", "court": ", Wyoming Supreme Court", "year": "2022", "quote": "", "what_it_shows": "The opinion describes nursing entries on a fetal monitoring strip for 8:15–8:20 a.m. that were actually created at 4:06–4:08 p.m. the same day. Roughly eight hours separated the event times from the creation times. The court held that audit trails qualified as health care information under the applicable, now-repealed Wyoming statute. It reversed the judgment for the hospital and sent the case back for further proceedings because factual questions remained about compliance with the records law. This was a records-disclosure decision. It was not a malpractice verdict about delayed charting. The point for your charting: a record can show both the time assigned to an observation and the later time when you entered it." }, { "case": "Gilbert v. Highland Hospital", "url": "https://www.courtlistener.com/opinion/6317072/gilbert-v-highland-hospital/", "court": ", New York Supreme Court", "year": "2016", "quote": "", "what_it_shows": "The court ordered production of an audit trail because the allegations made it relevant to know whether an emergency department attending had reviewed the patient’s electronic record and care plan before discharge. The court also made clear what the audit trail couldn't show: physician actions that didn't involve accessing or viewing the electronic record. Chart activity can help piece together a timeline. It doesn't capture all bedside care." } ], "guidance": [ { "says": "Chart while the details are fresh. The longer you wait, the more likely you are to misremember or leave something out.", "sources": [ { "name": "Nurse.com", "url": "https://www.nurse.com/blog/is-it-legal-to-go-back-and-finish-documenting-on-a-patient-a-day-or-even-a-week-later/" }, { "name": "Medical Transcription Service Company", "url": "https://www.medicaltranscriptionservicecompany.com/blog/importance-of-real-time-data-entry-for-medical-reporting/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "late-entry", "title": "Adding a Missed Note Without Rewriting the Past", "search_title": "Late entry charting: adding a note after your shift", "question": "You forgot to chart something. What is the right way to add it now?", "asked_as": "late entry addendum charting after shift nurse", "cluster": "time", "url": "https://shiftiswild.com/notes/late-entry/", "markdown_url": "https://shiftiswild.com/notes/late-entry.md", "summary": "You finish your shift and remember something you did but never charted. Use your facility’s approved process to add it. Show when the care happened and when you’re writing the note.", "key_points": [ "Keep two times clear: when you’re making the entry and when you provided the care, including both dates. Don’t make today’s entry look like you wrote it yesterday.", "Use the approved late-entry, addendum, or correction workflow. Keep the original entry intact and authenticate the addition with your own credentials.", "Write only what you can accurately support. Don’t build a complete assessment from your usual routine or make up an exact time.", "Take care of current needs first. If the missing information could affect treatment now, tell the responsible clinician or current care team. Adding a note doesn’t replace that conversation.", "Off duty or dealing with a closed encounter? Contact the appropriate supervisor or health information management team. Arrange to complete the record through an authorized process instead of just waiting for your next shift. Don’t assume you have a 24-hour grace period." ], "one_thing": "Add the missing facts now. Keep it clear when the care happened and when you documented it.", "what_goes_wrong": "It’s easy to confuse **when you gave the care** with **when you created the record**. They’re not the same.\n\nSay you assessed a patient at 1930 and entered the findings at 0015 the next day. The assessment still happened at 1930. You documented it at 0015, on a different date. Keep both visible.\n\nIt may be appropriate to select the actual assessment time in your EHR’s designated event-time field. What you can’t do is make a later entry look like you wrote it at the time of care, or replace an earlier entry without keeping the correction history.\n\nThe other mistake is filling the gap with what *usually* happens: copying yesterday’s normal assessment, guessing a medication time, or charting a reassessment you meant to do. Now the problem isn’t just missing documentation. It’s unsupported documentation. A late entry records care that happened. It can’t turn planned care into completed care.", "rewrites": [ { "situation": "An entry written after midnight but presented as though it was entered during the previous evening:", "before": "09/11/2026 1930 — Assisted patient to ambulate 50 feet with walker. Patient denied dizziness.", "after": "Show both dates and times:\n\n09/12/2026 0015 — Late entry for care provided 09/11/2026 at 1930: Assisted patient to ambulate 50 feet with walker. Patient denied dizziness during ambulation. J. Lee, RN." }, { "situation": "A missing communication added without a reference point:", "before": "Also notified provider. No new orders.", "after": "Identify the original note and the communication:\n\n09/12/2026 0900 — Addendum to nursing note entered 09/11/2026 at 1810: At 1805 on 09/11/2026, notified A. Patel, NP, by telephone of temperature 38.2°C and heart rate 108/min. No new orders received during that call. J. Lee, RN." }, { "situation": "A guessed time presented as exact:", "before": "09/11/2026 1800 — Reinforced right forearm dressing with gauze.", "after": "State the timing you actually know:\n\n09/12/2026 0910 — Late entry for care provided during the 1500–2300 shift on 09/11/2026: Reinforced right forearm dressing with gauze. Exact time not recalled. J. Lee, RN." }, { "situation": "An inaccurate location silently replaced:", "before": "Right forearm dressing reinforced.\n\n*The earlier version identifying the left forearm has been overwritten.*", "after": "Use the correction workflow and preserve the original:\n\n09/12/2026 0920 — Correction to nursing note entered 09/11/2026 at 1810: The dressing reinforced was on the right forearm, not the left forearm. J. Lee, RN." } ], "words_to_avoid": [ { "wording": "Backdated to 1930", "why": "Suggests changing when the entry was created.", "instead": "Late entry entered [current date/time] for care provided [event date/time]." }, { "wording": "Assessment unchanged", "why": "Can conceal a reconstructed or unverified assessment.", "instead": "The specific findings you actually assessed and can accurately recall." }, { "wording": "1800, when the time is guessed", "why": "Makes uncertain timing look exact.", "instead": "A supported approximate time, or the known shift with exact time not recalled." }, { "wording": "Chart fixed", "why": "Does not identify what changed or which entry it concerns.", "instead": "Correction to note entered [date/time], followed by the specific correction." }, { "wording": "Provider aware", "why": "Leaves unclear who was contacted, when, and about what.", "instead": "The clinician’s name and role, communication time and method, information conveyed, and response." } ], "cases": [ { "case": "Healthcare Staffing Solutions, Inc. v. Wilkinson Ex Rel. Wilkinson", "url": "https://www.courtlistener.com/opinion/1632409/healthcare-staffing-solutions-inc-v-wilkinson-ex-rel-wilkinson/", "court": "District Court of Appeal of Florida", "year": "2009", "quote": "", "what_it_shows": "The nurse testified that she usually moved information from informal notes into patient charts, then threw the notes away. The hospital argued that this patient’s chart and flowsheet were essentially blank. The appellate court held that the trial court was wrong to apply a presumption of negligence based on the missing notes. But it found that error harmless because other evidence supported the negligence finding. It reversed on a separate allocation-of-fault issue. The ruling didn’t approve or prohibit any particular late-entry format." }, { "case": "Caminero v. New York City Health & Hospitals Corp.", "url": "https://www.courtlistener.com/opinion/5831984/caminero-v-new-york-city-health-hospitals-corp/", "court": "Appellate Division of the Supreme Court of the State of New York", "year": "2005", "quote": "", "what_it_shows": "The records included a discharge-summary addendum describing a pulse-oximeter-related foot injury. The appellate court relied on hospital records made at the time to find that the hospital already knew the essential facts of the claim. It reinstated the complaint. The late notice in this case concerned filing a claim—not a nursing late entry. The decision didn’t set rules for how you should enter an addendum." } ], "guidance": [ { "says": "Chart as close to the care as you can. Don’t routinely save it all for a later batch.", "sources": [ { "name": "Nurse.org", "url": "https://nurse.org/news/nursing-documentation-mistakes/" }, { "name": "CareerStaff", "url": "https://www.careerstaff.com/clinician-life-blog/nursing/charting-in-nursing-dos-and-donts/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "altering", "title": "Correct the record without rewriting the past", "search_title": "Altering a medical record: what spoliation means", "question": "Why is editing an old entry the worst thing you can do?", "asked_as": "altered medical record nurse spoliation lawsuit", "cluster": "time", "url": "https://shiftiswild.com/notes/altering/", "markdown_url": "https://shiftiswild.com/notes/altering.md", "summary": "A patient falls, a medication error comes to light, or a condition gets worse. Then you spot a mistake or a gap in your earlier note. If you quietly rewrite it, information you added afterward can look like it was there before the problem occurred. **Correcting the record is not the same as rewriting its history.**", "key_points": [ "Take care of the patient first. Do not let a charting problem delay assessment, treatment, or necessary notifications.", "Use the approved correction, addendum, or late-entry workflow. Keep the original entry and its history. Do not silently replace it.", "Keep the two times separate: when the care or event happened, and when you are documenting it.", "Stick to facts you can support. Do not fill in an assessment based on your usual routine or turn an uncertain memory into an exact time.", "Ask for help with the process if you need it. Contact your supervisor or health information management (HIM). If someone pressures you to document something untrue, use compliance channels." ], "one_thing": "Correct the facts. Make clear when the correction was made and who made it.", "what_goes_wrong": "The mistake is treating a completed note like a draft.\n\nAfter an adverse event, you may want to add a symptom, change a notification time, or fix an inaccurate assessment. Correcting the facts is not the problem. Making the change look like it was in the original note is.\n\nThat mixes up three different things:\n\n- What you observed at the time.\n- What you remember afterward.\n- What you learned later from someone else.\n\nSay a patient reports dizziness the morning after a fall. That does not establish that you assessed dizziness before the fall. Put that report into yesterday’s assessment, and you change how the sequence looks.\n\nA silent rewrite gives the reader another problem to sort out. Now they have to figure out not just what happened, but which information was in the original note and which came later.\n\n**You want an accurate record that someone can follow, not a smoother story.** Leaving a known error uncorrected is not the answer either.", "rewrites": [ { "situation": "Backdate a missing fall note the next morning:", "before": "09/12/2026 1400: Patient found seated on floor beside bed. Reports right hip pain 6/10. Charge nurse and Dr. Lee notified at 1405.", "after": "Identify both the entry time and event time:\n\n09/13/2026 0730 — Late entry for 09/12/2026 at 1400: Patient found seated on floor beside bed. Patient reported right hip pain rated 6/10. Charge nurse and Dr. Lee notified at 1405 on 09/12/2026." }, { "situation": "Replace an incorrect notification time without identifying the correction:", "before": "09/12/2026 1030: Dr. Lee notified at 1025.\n\n*The original entry said 1005.*", "after": "Make the changed fact explicit:\n\n09/13/2026 0815 — Correction to nursing note dated 09/12/2026 at 1030: Dr. Lee was notified at 1025, not 1005 as previously entered." }, { "situation": "Delete an inaccurate copied-forward assessment and substitute a vague statement:", "before": "09/12/2026 0900: Routine care completed.\n\n*The original entry incorrectly documented repositioning and intact sacral skin.*", "after": "Correct the unsupported statements without inventing replacement care:\n\n09/13/2026 0900 — Correction to nursing note dated 09/12/2026 at 0900: Repositioning and intact sacral skin were documented in error. I did not reposition the patient or assess the sacral area at that time." }, { "situation": "Insert newly obtained history into the earlier assessment:", "before": "09/12/2026 1400: Patient reports dizziness immediately before fall.\n\n*The patient first provided this information the following morning.*", "after": "Document when you actually obtained the information:\n\n09/13/2026 0940: Patient reports feeling dizzy immediately before the fall on 09/12/2026. This history was obtained today." } ], "words_to_avoid": [ { "wording": "Care provided per routine", "why": "Describes a habit, not what actually happened.", "instead": "State the specific care you performed and when." }, { "wording": "Must have notified provider", "why": "Turns an assumption into an apparent event.", "instead": "Record a notification only if you can support it; do not invent its time." }, { "wording": "Patient refused, added to explain a gap", "why": "Supplies a reason that may never have been established.", "instead": "Describe the actual offer of care and patient response, if known." }, { "wording": "Documentation corrected, with nothing else", "why": "Does not identify what was wrong or what is accurate.", "instead": "Correction to [date/time] entry: [incorrect fact] should read [accurate fact]." }, { "wording": "As previously documented, before newly added information", "why": "Makes new information appear to have been present earlier.", "instead": "Identify it as a late entry, addendum, or newly obtained history, as appropriate." } ], "cases": [ { "case": "Mississippi State Board of Nursing v. Robin Mack", "url": "https://www.courtlistener.com/opinion/10629315/mississippi-state-board-of-nursing-v-robin-mack/", "court": "Court of Appeals of Mississippi", "year": "2021", "quote": "", "what_it_shows": "The documentation charges included a disputed record of a face-to-face encounter after the nurse practitioner had left a cancellation message. The nursing board imposed probation. The chancery court reversed that decision, and the appellate court affirmed the reversal because the board’s decision lacked substantial evidence and was arbitrary and capricious. This decision did not establish intentional chart falsification. Keep that distinction clear: an accusation about documentation is not the same as what the evidence supports." }, { "case": "The Anthem Companies, Inc. v. Cheryl Wills", "url": "https://www.courtlistener.com/opinion/10367249/the-anthem-companies-inc-v-cheryl-wills/", "court": "Supreme Court of Georgia", "year": "2019", "quote": "", "what_it_shows": "This case involved photographs, not a nursing chart. Paper prints were lost, but digital versions were still available. The court reversed sanctions for failure to preserve evidence. The record did not support a finding that Anthem had altered the images it received. The connection to charting is narrow but useful. Losing a duplicate, keeping an electronic original, and altering evidence are different things. This decision does not give you permission to change a patient record after an incident." } ], "guidance": [], "ready_to_copy": "", "samples_are_written": true }, { "slug": "billable-visit", "title": "When the Billable Visit Did Not Happen", "search_title": "", "question": "What should I chart when a billable nursing or behavioral health service was missed, shortened, interrupted, or never provided?", "asked_as": "nursing forum missed visit shortened visit Medicaid charting actual time service not provided", "cluster": "time", "url": "https://shiftiswild.com/notes/billable-visit/", "markdown_url": "https://shiftiswild.com/notes/billable-visit.md", "summary": "The visit is on the schedule. The auth may still be sitting there. That does not mean you chart a visit that did not happen.\nYour note has one job: show the real event. No service. Partial service. Interrupted service. Actual minutes only.", "key_points": [ "Do not use the normal visit template when the normal visit did not happen.", "Chart the real contact: none, start and stop time, or the minutes you actually provided.", "Say what was missed or not finished. Do not blame. Do not guess.", "Document who you notified, when, and the plan to reschedule or follow up.", "Use the visit status or billing workflow that keeps a scheduled service from looking completed." ], "one_thing": "Chart the service that really happened, not the service the schedule expected.", "what_goes_wrong": "This usually starts with the EHR.\n\nThe template, macro, or schedule expects a complete visit, so the note gets left looking complete.\n\nNow the chart and the day do not match. The note says education was done, vitals were reviewed, a group was attended for 60 minutes, or a home visit was completed. But that is not what happened. The patient was not home. The session ended after 15 minutes. The patient refused. The nurse was pulled to an emergency. The required second staff member was not available.\n\nMissed care happens. Short visits happen too.\n\nThe problem is when the record hides that miss by using completed-visit language.", "rewrites": [ { "situation": "", "before": "SN visit completed. Patient not home.", "after": "05/12/2026 0915 Scheduled skilled nursing visit not provided. Arrived at home at 0905; no answer at door. Called patient at 0908 and caregiver at 0910; no answer. No assessment or skilled nursing care provided. Scheduler and RN supervisor J. Smith notified at 0915. Visit status updated as missed visit." }, { "situation": "", "before": "Group completed 60 min.", "after": "05/12/2026 Behavioral health skills group scheduled 1000-1100. Client arrived at 1025 and left at 1050 for transportation. Actual group time 25 minutes. Client participated in grounding exercise and check-out. No safety concerns stated during time present. Note reflects actual time present only." }, { "situation": "", "before": "Diabetes teaching done.", "after": "05/12/2026 1410 Diabetes teaching started with focus on insulin storage. Teaching stopped at 1420 when patient reported new shortness of breath. VS at 1422: BP 168/92, HR 112, RR 24, SpO2 91% RA. Provider notified at 1425; patient instructed to remain seated while awaiting further direction. Education not completed. Follow-up teaching needed." }, { "situation": "", "before": "Turned q2h.", "after": "05/12/2026 1400 scheduled repositioning not completed at scheduled time. Patient required two-person assist; second staff member not available 1355-1425 due unit acuity. Charge RN M. Lee notified at 1405. Patient repositioned to left side with pillows at 1430 with CNA assist. Sacrum intact, no redness noted at 1430." }, { "situation": "", "before": "Patient refused visit.", "after": "05/12/2026 1135 Home health aide visit not provided. Patient answered phone and stated she did not want a visit today due fatigue. Risks of missed bathing and skin check reviewed. Patient denied pain, dizziness, fall, or urgent need by phone. Scheduler notified at 1140 to offer next available visit." }, { "situation": "", "before": "Assessment WNL.", "after": "05/12/2026 Scheduled nursing assessment not completed. Patient left clinic at 1510 before nurse assessment due transportation arrival. No vital signs, medication review, or wound assessment performed by this nurse. Front desk notified RN at 1515. Patient contacted by phone at 1525; message left requesting call back to reschedule." }, { "situation": "", "before": "Visit done per plan.", "after": "05/12/2026 Planned behavioral health case management visit was interrupted after 12 minutes when client was called to court hearing by phone. Actual contact 1300-1312. Discussed medication pickup barrier and confirmed pharmacy name. Housing paperwork and coping-skills review not completed. Follow-up appointment offered for 05/13/2026." } ], "words_to_avoid": [ { "wording": "Completed", "why": "Sounds like the full planned service happened", "instead": "Not provided, partially completed, completed for actual time of [MINUTES]" }, { "wording": "Done", "why": "Too vague. It does not say what you actually did", "instead": "[INTERVENTION] performed at [TIME]" }, { "wording": "Tolerated well", "why": "Does not help if the service was missed or cut short", "instead": "Patient response: [FACTS OBSERVED OR STATED]" }, { "wording": "WNL", "why": "Makes it sound like you assessed the patient", "instead": "No assessment performed, or list actual findings" }, { "wording": "Per plan", "why": "Hides the part of the plan that did not happen", "instead": "Planned [ITEM] not completed because [FACT]" }, { "wording": "No-show", "why": "Not enough by itself", "instead": "Patient not present at [TIME]; contact attempts [DETAILS]" }, { "wording": "Refused", "why": "Not enough by itself", "instead": "Patient declined [SERVICE]; reason stated [REASON]; follow-up [PLAN]" }, { "wording": "Staffing issue", "why": "Too vague and defensive", "instead": "Required [NUMBER]-person assist; [ROLE] unavailable from [TIME] to [TIME]; [NAME/ROLE] notified" }, { "wording": "Late charting", "why": "Does not explain what happened with the care", "instead": "Late entry for [DATE/TIME]: [FACTS OF CARE OR MISSED CARE]" }, { "wording": "Full session", "why": "Wrong if the patient arrived late, left early, or got interrupted", "instead": "Actual service time [START]-[STOP], total [MINUTES]" } ], "cases": [ { "case": "People v. Rowjee", "url": "https://www.courtlistener.com/opinion/3138931/people-v-rowjee/", "court": "Appellate Court of Illinois", "year": "1999", "quote": "", "what_it_shows": "The opinion describes a public aid billing review where billed service dates were compared with patient charts. This line shows the issue clearly: “People's Exhibit S-1 purports to list days where defendant billed where there was no matching documentation by defendant in the patient's chart.” For charting, keep it simple: if the billing trail says a service happened, the care record needs to show what actually happened." } ], "guidance": [ { "says": "Do not chart planned care as performed care. Keep the entry accurate, complete, and in time order: what happened, what did not happen, who was notified, and the next step.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" }, { "name": "TextExpander", "url": "https://textexpander.com/blog/examples-of-nursing-documentation-errors" } ] }, { "says": "A nurse visit is not billable just because it was scheduled. The record should show that staff actually saw the patient, and some nurse contacts are not charged.", "sources": [ { "name": "HRSA", "url": "https://bphc.hrsa.gov/sites/default/files/bphc/data-reporting/uds-nurse-visits.pdf" }, { "name": "HMP Global Learning Network", "url": "https://www.hmpgloballearningnetwork.com/site/thederm/site/cathlab/event/billing-the-nurse-visit" } ] }, { "says": "Record the communication, education, instructions, and patient response that actually occurred. If teaching or counseling was interrupted, document the part completed and the part still needed.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" }, { "name": "Nursa", "url": "https://nursa.com/blog/nurse-charting-documentation-made-easy-with-examples" } ] } ], "ready_to_copy": "[DATE] [TIME] Scheduled [SERVICE TYPE] visit for [PATIENT NAME/ID] was not provided. Reason: [WHAT HAPPENED]. Actual patient contact: [NONE / PHONE ONLY / BRIEF CONTACT DETAILS]. Assessment performed: [NONE / BRIEF FINDINGS]. Care or treatment provided: none. Attempts to reach patient/caregiver: [DETAILS WITH TIMES]. Notifications: [NAME/ROLE] notified at [TIME]. Plan: [RESCHEDULE / PROVIDER NOTIFIED / NEXT VISIT DATE / OTHER FOLLOW-UP]. Visit status updated as [MISSED VISIT / NON-BILLABLE / OTHER STATUS] per workflow.", "samples_are_written": true }, { "slug": "code-role-note", "title": "Charting During a Code When Your Hands Were Full", "search_title": "", "question": "What should I write if I was giving meds, doing compressions, calling the provider, or recording during a code and could not chart everything in real time?", "asked_as": "nurse code blue documentation role recorder compressions medications late charting", "cluster": "time", "url": "https://shiftiswild.com/notes/code-role-note/", "markdown_url": "https://shiftiswild.com/notes/code-role-note.md", "summary": "In a code, your hands may be full: meds, compressions, provider calls, supplies, and questions coming from three directions. If you couldn't chart in real time, say that. Don't make the note look like you were calmly standing there time-stamping every move.\nChart your lane. What you did. What you saw. What clock or record you used. And what you did not see yourself.", "key_points": [ "Don't rebuild the whole code unless you were the recorder. Chart your role and your actions.", "If you chart later, call it a late entry and include the time you are writing the note.", "For meds, chart the drug, dose, route, access, time, order or protocol, and whether you announced it to the recorder.", "For compressions, chart when you started, when someone relieved you, and any pulse or rhythm checks you personally saw or heard announced.", "If you don't know the exact time, say approximate or name the source: code record, monitor, MAR, wall clock, or another team member." ], "one_thing": "Don't chart the whole code if you couldn't see the whole code. Chart your role, your actions, your times, and your source.", "what_goes_wrong": "The usual mistake is trying to back-chart a clean minute-by-minute timeline when you were not the recorder.\n\nThat gets messy fast. A code note can pull from four places: what you personally saw, what someone called out, what the monitor or MAR shows, and what you pieced together later. If you don't label the source, the next person can't tell whether a time is exact, approximate, or secondhand.\n\nA good code note is not prettier. It is clearer: I was the medication nurse from this time to this time. I gave these meds. These times came from the MAR or code record. I did not personally see the first few minutes.", "rewrites": [ { "situation": "", "before": "Code started around 0950. I helped.", "after": "Late entry at 1038 for Code Blue in Room 412. This RN arrived at 0953 and served as medication nurse from 0955 to 1008. Events before 0953 were not personally observed by this RN." }, { "situation": "", "before": "Epi given x3.", "after": "Epinephrine 1 mg IV push given via right AC PIV at 0956 per Dr. Patel verbal order during code. Flushed with 20 mL NS. Medication and time announced to code recorder. Additional epinephrine doses documented in MAR at 1000 and 1004." }, { "situation": "", "before": "Did CPR until team arrived.", "after": "At 0952, patient found unresponsive with no pulse palpated by this RN. Code Blue activated. Chest compressions started by this RN at 0952 and continued until relieved by J. Lee RN at 0955. This RN resumed compressions from 1002 to 1004." }, { "situation": "", "before": "MD aware.", "after": "Dr. Nguyen called at 1006 per code leader request. Reported active Code Blue in Room 412, CPR in progress, pulseless rhythm, epinephrine administered per code record. Dr. Nguyen stated she was en route and arrived at bedside at 1011." }, { "situation": "", "before": "Recorder for code. See code sheet.", "after": "Recorder role assumed at 0954. Times after 0954 documented from wall clock and team verbal announcements/read-backs. Events before 0954 entered only when reported by bedside RN or shown on monitor/MAR and marked as reported." }, { "situation": "", "before": "Patient coded at 1000.", "after": "Approx. 0950, patient noted unresponsive by CNA per report to this RN. Exact time of initial change not observed by this RN. This RN arrived at 0952 and found CPR in progress." }, { "situation": "", "before": "Strips sent with patient.", "after": "Defibrillator/monitor strips from Code Blue labeled with patient name, MRN, date, and time. Strips given to C. Adams RN, ICU receiving nurse, at 1025 for scanning per unit process." }, { "situation": "", "before": "Could not chart because code was crazy.", "after": "Late entry entered at 1120. This RN provided direct patient care during Code Blue from 0953 to 1015 and did not enter EHR documentation during that interval. Times in this note are from MAR, code record, and wall clock unless noted as approximate." } ], "words_to_avoid": [ { "wording": "Crashed", "why": "Too vague. It hides what actually changed.", "instead": "Became unresponsive; no pulse palpated; monitor showed [RHYTHM]." }, { "wording": "Finally", "why": "Sounds like blame and does not give facts.", "instead": "At [TIME], [NAME/ROLE] arrived at bedside." }, { "wording": "Nobody was recording", "why": "Turns the note into a complaint.", "instead": "Recorder role assumed at [TIME]; prior events entered from [SOURCE]." }, { "wording": "MD aware", "why": "Too vague to help the next clinician.", "instead": "[PROVIDER NAME] notified at [TIME] of [FINDINGS]; response/orders: [RESPONSE]." }, { "wording": "I was too busy to chart", "why": "Self-focused and informal.", "instead": "Late entry entered at [TIME]; this RN provided direct care from [TIME] to [TIME]." }, { "wording": "Per ACLS", "why": "Not enough by itself.", "instead": "CPR started at [TIME]; epinephrine 1 mg IV given at [TIME]; rhythm check at [TIME] showed [RHYTHM]." }, { "wording": "I think", "why": "Makes the whole entry sound uncertain.", "instead": "Approx. [TIME] or time from [SOURCE]." }, { "wording": "Stable after code", "why": "Too broad.", "instead": "ROSC at [TIME]; BP [VALUE], HR [VALUE], SpO2 [VALUE] on [OXYGEN/VENT SETTINGS]; transferred to [UNIT] at [TIME]." }, { "wording": "Everyone was confused", "why": "Blame language, not patient care documentation.", "instead": "Multiple team members present; code leader identified as [NAME/ROLE] at [TIME]." }, { "wording": "Late meds", "why": "Vague and judgmental unless tied to exact facts.", "instead": "[MEDICATION] given at [TIME]; scheduled time [TIME]; reason not given at scheduled time: patient in active Code Blue/direct care in progress." } ], "cases": [ { "case": "The Private Bank v. Silver Cross Hospital and Medical Centers", "url": "https://www.courtlistener.com/opinion/4506412/the-private-bank-v-silver-cross-hospital-and-medical-centers/", "court": "Appellate Court of Illinois", "year": "2018", "quote": "According to Alling’s testimony, her primary focus was treating Reynolds’s serious condition, so she did not have the extra time necessary to write her notes contemporaneous with his treatment.", "what_it_shows": "The decision described a code timing dispute where a nurse’s notes were written after the event because patient care came first" }, { "case": "Commonwealth", "url": "https://www.courtlistener.com/opinion/2292292/commonwealth-state-board-of-nurse-examiners-v-rafferty/", "court": "State Board of Nurse Examiners v. Rafferty, Supreme Court of Pennsylvania", "year": "1985", "quote": "It was undisputed that the cardiac monitor strip documenting the rare PVCs was not attached to the patient’s chart.", "what_it_shows": "The court reviewed a nurse discipline matter involving conduct around resuscitation and documentation of rhythm evidence" }, { "case": "Finnerty v. Board of Registered Nursing", "url": "https://www.courtlistener.com/opinion/2285903/finnerty-v-board-of-registered-nursing/", "court": "California Court of Appeal", "year": "2008", "quote": "Dr. Nguyen entered a “code blue note” on the patient’s record at 7:45 a.m., recording the incident substantially as described above.", "what_it_shows": "The record included later emergency documentation after an airway/code sequence" }, { "case": "Goldhammer v. Lincoln Anesthesiology Group", "url": "https://www.courtlistener.com/opinion/4766103/goldhammer-v-lincoln-anesthesiology-group/", "court": "Nebraska Court of Appeals", "year": "2020", "quote": "On appeal, Goldhammer challenges the district court’s decision to not admit exhibit 50, an alleged “code blue” document, despite repeated attempts to offer the exhibit through various witnesses.", "what_it_shows": "A code blue document itself became an issue in the appeal" } ], "guidance": [ { "says": "Keep the note factual and centered on the patient: what you saw, what you did, who you notified, and what happened next.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" }, { "name": "connectRN", "url": "https://www.connectrn.com/blog/how-to-get-your-charting-done-on-time" } ] }, { "says": "Chart as soon as you can after the event. The longer you wait, the easier it is for times and details to get mixed together.", "sources": [ { "name": "Nurse.org", "url": "https://nurse.org/news/nursing-documentation-mistakes/" }, { "name": "connectRN", "url": "https://www.connectrn.com/blog/how-to-get-your-charting-done-on-time" } ] }, { "says": "Put medication administration in the MAR. Add a progress note when the situation needs context or you need to document the patient's response.", "sources": [ { "name": "OpenStax", "url": "https://openstax.org/books/clinical-nursing-skills/pages/11-3-documentation-of-medication-administration" }, { "name": "NPHire", "url": "https://www.nphire.com/blog/top-5-np-charting-errors-and-how-to-prevent-them" } ] }, { "says": "Use plain wording. Skip vague phrases and unapproved abbreviations.", "sources": [ { "name": "TextExpander", "url": "https://textexpander.com/blog/examples-of-nursing-documentation-errors" }, { "name": "Nurse.org", "url": "https://nurse.org/news/nursing-documentation-mistakes/" } ] } ], "ready_to_copy": "[DATE] [TIME] Late entry for Code Blue event on [DATE] beginning at approximately [EVENT TIME]. This RN responded to [LOCATION] at [ARRIVAL TIME]. Role during event: [MEDICATION NURSE / COMPRESSIONS / PROVIDER CALLS / AIRWAY ASSIST / OTHER].\n\nPatient status on this RN arrival: [PATIENT STATUS OBSERVED].\n\nInterventions personally performed by this RN: [INTERVENTION 1 WITH TIME], [INTERVENTION 2 WITH TIME], [INTERVENTION 3 WITH TIME].\n\nMedication administration by this RN: [DRUG], [DOSE], [ROUTE], via [IV/IO/OTHER ACCESS] at [TIME] per [PROVIDER VERBAL ORDER / CODE PROTOCOL / OTHER ORDER]. Medication and time were announced to [RECORDER NAME/ROLE] at time given. MAR updated at [TIME].\n\nCommunications by this RN: [PROVIDER/TEAM MEMBER NAME AND ROLE] notified at [TIME]. Information given: [BRIEF FACTS REPORTED]. Response/orders: [RESPONSE OR ORDERS RECEIVED].\n\nThis RN was providing direct patient care from [TIME] to [TIME] and did not chart in the EHR during that interval. Times in this entry are from [WALL CLOCK / MONITOR / MAR / CODE RECORD / APPROXIMATE FROM MEMORY] unless otherwise stated.\n\nHandoff/report given to [NAME/ROLE] at [TIME]. Patient disposition at end of this RN involvement: [ROSC / TRANSFER TO ICU / CPR ONGOING / PRONOUNCED BY PROVIDER / OTHER].", "samples_are_written": true }, { "slug": "incident-report", "title": "Keep the incident report out of the patient chart", "search_title": "Is an incident report discoverable? Never chart it", "question": "Why does one sentence turn a protected report into evidence?", "asked_as": "incident report discoverable nurse chart mention", "cluster": "trouble", "url": "https://shiftiswild.com/notes/incident-report/", "markdown_url": "https://shiftiswild.com/notes/incident-report.md", "summary": "After a fall, medication error, or equipment problem, you have two jobs: document the patient’s care and complete the appropriate safety report. Keep them separate. But don’t turn that advice into a legal claim the cases here don’t support: that one sentence in the chart automatically turns a protected report into evidence.", "key_points": [ "Chart the event and the care: what you observed, your assessment, whom you notified, what you did, and how the patient responded.", "Complete the incident report through your facility’s designated reporting process. Keep it separate from the clinical note.", "Don’t mention the report instead of documenting what happened. Don’t copy it into the chart, either.", "Keep clinically relevant safety concerns in the chart. Separating the documents does not mean hiding the event.", "Already mentioned a report? Don’t erase or overwrite the entry to try to protect it. Ask about your facility’s approved amendment process." ], "one_thing": "Keep the report separate. Not the facts about the patient’s safety and care.", "what_goes_wrong": "Writing *incident report completed* can feel like you’ve documented something useful. You’ve documented paperwork. The reader still doesn’t know whether the patient was injured, who assessed them, or what care followed.\n\nThe other mistake is treating legal protection like a switch.\n\n**An incident report isn’t automatically protected because of its name. And the cases here don’t establish that merely mentioning one automatically removes its protection.** These decisions look at how the information was created and used, and whether it was part of a qualifying review process.\n\nKeep these actions separate:\n\n- **Documenting the event** records the patient’s condition and care. Put that in the chart.\n- **Mentioning the report** records that another document exists. That alone doesn’t tell you whether the document is protected.\n- **Copying the report’s contents** puts those words in the clinical record as well as the reporting system. That’s different from saying a report exists.\n\nYou also need to distinguish *discoverable* from *admissible*. Discoverable material can be required to be produced during a lawsuit. Admissible material can be used as evidence in court. Different questions.\n\nThe practical reason to keep the documents separate is simpler: your clinical note needs to explain the patient’s care without sending the reader to an internal report.", "rewrites": [ { "situation": "", "before": "Patient fell. Incident report completed.", "after": "1420: Patient found seated on floor beside bed. Fall not witnessed by this RN. Alert and oriented to person, place, time, and situation. Reports right hip pain rated 6/10. BP 128/74, HR 86, RR 18, SpO₂ 97% on room air. 1424: Dr. Lee notified of findings. Patient remained under direct observation. 1428: Dr. Lee at bedside for assessment." }, { "situation": "", "before": "Morning antibiotic missed. Variance report filed.", "after": "0930: Review of MAR identified that the scheduled 0800 cefazolin dose had not been administered. 0935: Dr. Lee and pharmacist notified of omitted dose; administration schedule clarified. 0945: Cefazolin administered according to updated order; dose and infusion details recorded in MAR. 1015: Patient denies itching or shortness of breath; no rash observed." }, { "situation": "", "before": "Pump malfunctioned. See incident report for details.", "after": "1012: Infusion pump screen went blank and infusion stopped while connected to AC power. IV site without redness, swelling, or leakage. 1015: Infusion resumed using replacement pump at the ordered rate; settings verified against active order. Malfunctioning pump removed from patient use. 1025: Replacement pump operating; infusion site unchanged." }, { "situation": "", "before": "Family silenced alarm again. Re-educated. Safety report submitted.", "after": "1610: Observed family member press the monitor’s alarm-silence button while alarm sounded. Patient awake; SpO₂ 96% on room air, RR 16, breathing unlabored. Explained that family should use the call light for monitor alarms and leave monitor controls to staff. Family member demonstrated call-light use and stated understanding." } ], "words_to_avoid": [ { "wording": "Incident report completed", "why": "Describes paperwork, not the patient’s condition or care.", "instead": "Assessment findings, actions, notifications, and response." }, { "wording": "See incident report for details", "why": "Leaves the clinical account incomplete.", "instead": "The relevant event details in the clinical note itself." }, { "wording": "Per incident report", "why": "Makes another document the source of the clinical account.", "instead": "What you observed, or information attributed to the person who provided it." }, { "wording": "Risk management investigating", "why": "Does not explain the patient’s current care plan.", "instead": "Clinically relevant notifications, resulting orders, and follow-up." } ], "cases": [ { "case": "Robert D. Toler v. Cornerstone Hospital of Huntington, LLC", "url": "https://www.courtlistener.com/opinion/9406999/robert-d-toler-v-cornerstone-hospital-of-hungintgon-llc/", "court": "Supreme Court of Appeals of West Virginia", "year": "2023", "quote": "", "what_it_shows": "A hospital visitor fell, sustained a fracture, and later sought the incident report. The appellate court upheld protection of the report under the peer-review privilege. The legal test reproduced in the decision focused on exactly where the document came from and how it was used. Not just what it was called. The nurse who prepared the report could still testify about what he personally knew of the fall’s circumstances. Protecting the report did not prevent testimony about independently known facts. This was not a ruling that a chart reference destroyed protection." }, { "case": "Zander v. Craig Hospital", "url": "https://www.courtlistener.com/opinion/2477065/zander-v-craig-hospital/", "court": "U.S. District Court for the District of Colorado", "year": "2010", "quote": "", "what_it_shows": "A patient alleged that negligence during spinal surgery caused paralysis. The hospital claimed protection for investigative material, arguing broadly that its approved quality-management program protected all discussions about medical care. The court rejected that position. The decision explains that protection covered information resulting from activities described in the state-approved program. Documents that existed independently of those activities could still be obtained from their original sources through discovery. Conversations outside the qualifying process weren’t protected, either. The distinction was about the source and the process. It wasn’t about a nurse writing one sentence about filing a report." } ], "guidance": [ { "says": "Don’t put statements that an incident report was prepared or filed in the patient’s chart.", "sources": [ { "name": "LevelUpRN", "url": "https://leveluprn.com/blogs/nursing-tips/incident-reports" }, { "name": "allnurses", "url": "https://allnurses.com/nurses-notes-guidelines-on-what-t519366/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "refusal", "title": "Documenting a refusal so the note tells the whole story", "search_title": "How to document a patient refusal and AMA", "question": "The patient said no. What has to be in the note?", "asked_as": "patient refusal documentation AMA nurse charting", "cluster": "trouble", "url": "https://shiftiswild.com/notes/refusal/", "markdown_url": "https://shiftiswild.com/notes/refusal.md", "summary": "The patient said no to a medication, a treatment, or staying in the hospital. Don’t stop there. Your note needs to show what you offered, what the patient understood, what they chose, and what happened next.", "key_points": [ "Name the decision. Write down the treatment, medication, test, or assessment you offered and the time. Did the patient decline all of it, decline part of it, or ask to wait?", "Include the patient’s reason and relevant findings. Record what the patient told you and what you observed. Don’t guess at motives.", "Describe the discussion. Document the purpose, the risks specific to this patient, the alternatives discussed, who explained them, and how the patient responded.", "Close the communication loop. Name whom you notified and when. Include what you reported, the response, and anything that still needs follow-up.", "Show the continuing plan. Record care the patient accepted, reassessment, or another offer. If the patient leaves, include departure details, the instructions you actually provided, and whether they signed." ], "one_thing": "Document the offer, the discussion, the patient’s decision, and your next step. Not just the no.", "what_goes_wrong": "The common mistake is stopping at the refusal.\n\nA note that says only *Patient refused* leaves the next nurse guessing. One dose or all medication? Was pain making a turn difficult? Did the patient want an explanation, an alternative, or another ten minutes?\n\n**Refused versus declined is not the main issue.** Use your EHR’s terminology neutrally. Don’t use either word to signal whether the patient was polite. What matters is the decision and what was happening around it.\n\nDocumenting education is only part of the job. You also need the patient’s response. *Verbalized understanding* doesn’t tell the next nurse what the patient understood. When relevant, record how the patient explained the purpose or consequences back to you.\n\nAn AMA signature doesn’t tell the story of the conversation, either. No wording guarantees a legal outcome. This is a practical charting framework, not legal advice.", "rewrites": [ { "situation": "", "before": "Patient refused Lovenox. Educated.", "after": "0900: Scheduled enoxaparin 40 mg subcutaneous offered. Patient declined, reporting painful bruising after previous injections. Reviewed purpose of medication for blood-clot prevention during reduced mobility and risk of a clot without recommended prophylaxis. Patient explained the medication’s purpose and continued to decline. Dose not administered. 0910: Dr. Chen notified of refusal and patient’s reported concern. 0915: Dr. Chen responded and plans bedside review of prophylaxis options. Follow-up pending." }, { "situation": "", "before": "Patient noncompliant with turning.", "after": "1400: Patient declined full left-side turn, reporting left hip pain 7/10 and requesting pain medication before repositioning. Reviewed pressure-injury risk from remaining in one position. Patient explained the need to relieve pressure and accepted a small assisted weight shift and heel off-loading. PRN analgesic administered at 1405; see MAR. 1435: Pain 3/10. Patient accepted assisted repositioning." }, { "situation": "", "before": "Leaving AMA. Risks explained. Papers signed.", "after": "1610: Patient requested departure before recommended repeat troponin testing, citing childcare needs. 1615: Dr. Patel at bedside recommended continued evaluation and discussed possible heart attack, serious deterioration, and death if evaluation or treatment is delayed. RN present. Patient explained that initial testing had not ruled out a heart attack and that leaving could delay treatment; continued to request departure. Dr. Patel assessed decision-making capacity; see provider note. Offered assistance contacting family and social work; patient declined. 1630: Denies chest pain or shortness of breath. BP 128/76, HR 84, RR 16, SpO₂ 98% on room air. IV removed; site dry. Reviewed written instructions, including immediate return for chest pain, shortness of breath, fainting, or worsening symptoms, and follow-up listed on discharge instructions. Patient signed AMA form and left ambulatory with sister at 1635." }, { "situation": "", "before": "Refused AMA paperwork. Left.", "after": "1742: Patient declined to sign AMA form and walked toward exit. Did not provide a reason for leaving when asked. Asked patient to wait for clinician discussion; patient continued toward exit. Departed at 1744 before clinician discussion, repeat vital signs, or written instructions could be completed. 1745: Dr. Lee and charge RN notified of departure and incomplete assessment and counseling. 1750: Attempted callback to number in chart; no answer." } ], "words_to_avoid": [ { "wording": "Noncompliant", "why": "Labels the patient without identifying the decision or barrier.", "instead": "The specific care declined, the stated reason, and care accepted." }, { "wording": "Refused everything", "why": "Hides which offers were actually made.", "instead": "Each significant treatment or assessment offered and the response." }, { "wording": "Understands all risks", "why": "Claims more than the note demonstrates.", "instead": "The specific risks discussed and what the patient explained back." }, { "wording": "A&O ×4; competent", "why": "Uses orientation as a shortcut for a different assessment.", "instead": "Relevant observations, the patient’s explanation, and clinician assessment when obtained." }, { "wording": "MD aware", "why": "Does not identify the person, information shared, or response.", "instead": "Clinician name, notification time, key findings reported, response, and pending follow-up." }, { "wording": "All options exhausted", "why": "Gives a conclusion without the steps behind it.", "instead": "Specific assistance, alternatives, notifications, and their results." } ], "cases": [ { "case": "John S. Zablotny v. State Board of Nursing", "url": "https://www.courtlistener.com/opinion/4348590/john-s-zablotny-v-state-board-of-nursing/", "court": ", Supreme Judicial Court of Maine", "year": "2017", "quote": "", "what_it_shows": "The patient signed AMA paperwork and left the hospital on foot in blizzard-like conditions. The trial court found that the nurse had engaged in unprofessional conduct by failing to give accurate and complete information about the risks of leaving. Maine’s Supreme Judicial Court affirmed that judgment. But the court did not find against the nurse on every allegation. The trial court also found that the Board had not proved the separate alleged violations involving incomplete information to the physician and failure to immediately notify police or the emergency contact. Those findings remained in place. See paragraphs 1 and 13–14. The decision also describes a day-shift report with suicidal comments that had not been properly placed in the patient’s chart. The nurse found it after the patient left, then made calls. That is the documentation gap: the information had been written down somewhere, but it wasn’t available when the departure decision was made. See paragraph 9. This case was about care and communication—not whether a particular charting verb was acceptable." } ], "guidance": [ { "says": "Put your assessment findings and plan of care in the record.", "sources": [ { "name": "Montgomery College", "url": "https://pressbooks.montgomerycollege.edu/healthassessment/chapter/documentation-of-health-assessment-findings/" }, { "name": "Nursa", "url": "https://nursa.com/blog/nursing-admission-note" } ] }, { "says": "Keep your entries factual and objective. Leave out your opinions.", "sources": [ { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" }, { "name": "Nursa", "url": "https://nursa.com/blog/nursing-admission-note" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "staffing", "title": "Where to document an assignment you objected to", "search_title": "Assignment Despite Objection: what to file and what to chart", "question": "You said the assignment was unsafe. Where does that go?", "asked_as": "assignment despite objection ADO form protest of assignment document short staffing unsafe assignment nurse", "cluster": "trouble", "url": "https://shiftiswild.com/notes/staffing/", "markdown_url": "https://shiftiswild.com/notes/staffing.md", "summary": "You told the charge nurse the assignment was unsafe. Put that concern through your facility’s designated staffing-objection process. In each affected patient’s chart, document the patient-specific care facts. Different records. Different jobs. Neither replaces the other.", "key_points": [ "Raise the concern promptly. Spell out where patient needs exceed the staff, skills, equipment, or supervision available. Ask for a specific change. If you need urgent help, don’t wait for paperwork.", "Use the right channel for the objection. Your workplace may use an Assignment Despite Objection (ADO), Protest of Assignment, or another staffing-reporting process. Record the time, assignment, concern, who you notified, what help you requested, the responses, and the follow-up.", "Chart what happened to the patient. Include assessments, care actually provided, relevant delays or omissions, notifications, interventions, and the patient’s response. Keep the argument about management out of it.", "Keep the records separate but consistent. Complete a safety-event report when policy requires one. Submit and keep records only through authorized channels, including an approved union process where applicable. Don’t use personal email or take phone photos of patient information." ], "one_thing": "Put the assignment concern through the staffing process. Chart its actual effect on each patient in that patient’s record.", "what_goes_wrong": "One sentence about short staffing cannot do every job.\n\nA staffing objection explains **why the assignment raised a safety concern and what help you requested**. The patient chart explains **what happened to that patient and what care followed**. A safety-event report goes through a separate reporting and review process.\n\nA general complaint in the chart tells you nothing about the patient’s condition. An ADO doesn’t document the patient’s missed medication, delayed repositioning, or reassessment.\n\nDon’t make the opposite mistake, either: leaving out clinically relevant facts because staffing was involved. If you couldn’t get necessary help and care was delayed, document the specific barrier and the clinical response. Leave out blame. Don’t make late care look on time.\n\nAnd don’t use an objection form to declare that responsibility has passed to someone else or that you’ve been released from it. The cited cases don’t establish that result. This article is about documentation, not whether you may refuse an assignment or leave.", "rewrites": [ { "situation": "", "before": "Unsafe assignment. Too many patients.", "after": "Staffing-objection record: 0705—Assigned six patients, including two requiring hourly neurologic checks. Concern: overlapping assessment times without identified RN coverage. Charge RN notified at 0705; requested redistribution of one patient requiring hourly checks or designated RN coverage. Charge RN reported no additional RN currently available. Nursing supervisor notified at 0715; coverage request repeated." }, { "situation": "", "before": "Management knew. Nothing changed.", "after": "Staffing-objection follow-up: 0730—Nursing supervisor notified by telephone of assignment concern and request for additional RN coverage. Supervisor stated float RN expected at 0800. At 0810, float RN had not arrived; supervisor contacted again. At 0820, float RN arrived and assumed care of two patients after handoff. Revised assignment: four patients." }, { "situation": "", "before": "Could not turn patient because we were short staffed.", "after": "Patient chart: 1400—Scheduled two-person repositioning delayed; second staff member unavailable. Charge RN notified at 1402 and assistance requested. At 1415, repositioned patient onto left side with RN assistance; heels offloaded. Sacral skin intact without erythema." }, { "situation": "", "before": "Previous shift neglected patient. Found soaked again.", "after": "Patient chart: 0710—Brief and gown wet with urine on initial assessment. Perineal skin erythematous and intact. Incontinence care provided; skin barrier applied per care plan. Dry brief and gown placed. Patient repositioned." }, { "situation": "", "before": "I refused the assignment.", "after": "Staffing-objection record, if care actually began: 0645—Objected to proposed assignment and requested reassignment of one patient requiring hourly neurologic checks. At 0700, received report and began care of assigned patients while request remained unresolved. At 0710, nursing supervisor notified of continuing concern and request for RN coverage." } ], "words_to_avoid": [ { "wording": "Unsafe, standing alone", "why": "States your conclusion without explaining the concern.", "instead": "Assignment details, required care, unavailable support, and requested change." }, { "wording": "Management aware", "why": "Does not identify who received what information or when.", "instead": "Name, role, time, method, concern communicated, and response." }, { "wording": "Nobody helped", "why": "Blurs requests, responses, delays, and assistance that eventually arrived.", "instead": "A timed sequence of requests and actual assistance." }, { "wording": "Patients neglected", "why": "Broadly assigns blame rather than describing what you found.", "instead": "Patient-specific findings, care provided, and relevant notifications." }, { "wording": "I accept no liability", "why": "Makes a legal declaration instead of recording the situation.", "instead": "The objection, requested correction, actual assignment status, and follow-up." }, { "wording": "Refused, when care began", "why": "Can conflict with the handoff and care record.", "instead": "A precise account of what you objected to and what you actually did." } ], "cases": [ { "case": "Tucker Nursing Center, Inc. v. Mosby", "url": "https://www.courtlistener.com/opinion/1404886/tucker-nursing-center-inc-v-mosby/", "court": "Court of Appeals of Georgia", "year": "2010", "quote": "", "what_it_shows": "The appellate court affirmed the judgment and found no abuse of discretion in admitting CNA testimony about staffing, supplies, and care during the resident’s stay. That testimony connected insufficient staffing to inadequate turning and repositioning. It also addressed what the facility knew about the conditions and complaints. This was testimony, not an ADO form. The point here is the connection between specific working conditions, a resident’s care needs, and notice to management. The court did not find that an objection form protects an individual nurse." } ], "guidance": [ { "says": "Put an unsafe-assignment concern in writing using the designated staffing-objection or protest form.", "sources": [ { "name": "Massachusetts Nurses Association", "url": "https://www.massnurses.org/labor-action/unsafe-staffing-forms/" }, { "name": "New York State Nurses Association", "url": "https://www.nysna.org/nurses-rights-know-your-rights/unsafe-assignments" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "unanswered-provider-call", "title": "What to chart when the provider does not call back", "search_title": "How to chart when the doctor does not call back", "question": "What should I document when a patient is deteriorating and the provider has not responded, from the findings and each contact attempt through escalation and reassessment?", "asked_as": "nurses how to chart doctor not calling back deteriorating patient chain of command", "cluster": "trouble", "url": "https://shiftiswild.com/notes/unanswered-provider-call/", "markdown_url": "https://shiftiswild.com/notes/unanswered-provider-call.md", "summary": "Your patient is getting worse, and the provider has not called back. Your note needs a timeline: findings, contact attempts, care, escalation, and reassessment. A message sent is only one part of it. If the patient needs emergency help, activate your facility’s emergency response process. Don’t wait for a callback or stop to finish a note.", "key_points": [ "Describe the change. Record your assessment findings, vital signs, and symptoms. Show what has changed from the patient’s baseline.", "Record each contact attempt. Include the time, who you tried to reach, how, what you told them, and what you requested. Document the response, or that you had no response as of a specific time.", "Show the escalation. Name who you contacted next and why. Include when they responded and what they did. Use emergency response pathways when indicated.", "Document care and reassessment. Record what you did within your scope and applicable orders or protocols. Follow that with timed findings showing how the patient responded.", "Close the loop. Include the provider’s evaluation, orders, transfer, or handoff. State any unresolved concerns and who is responsible for follow-up." ], "one_thing": "Chart what changed, every attempt to reach someone, how you escalated, and what happened to the patient next. The call alone is not the story.", "what_goes_wrong": "The mistake is treating a contact attempt as if it completed the clinical response.\n\n*MD notified* tells you very little. Did you speak with the physician, leave a voicemail, or send an electronic message? What findings did you report? Did anyone answer? What happened while you waited?\n\nA delivered message does not mean someone acknowledged the concern. An acknowledgment does not mean the patient has an assessment or treatment plan. And if the patient keeps getting worse, a returned call is not the end of the sequence.\n\nKeep these events separate in the record:\n\n**Finding → contact attempt → response or nonresponse → escalation and care → reassessment.**\n\nThis organizes your documentation. It does not mean you must make repeated calls before activating emergency help.", "rewrites": [ { "situation": "", "before": "Patient declining. Vitals abnormal.", "after": "14:00: New confusion; follows one-step commands but cannot identify location. BP 86/50 mm Hg, HR 124/min, RR 30/min with accessory muscle use, SpO₂ 88% on room air. At 13:30, patient was oriented to person, place, and time; BP 118/70, HR 88, RR 18, SpO₂ 96% on room air." }, { "situation": "", "before": "MD notified.", "after": "14:01: Urgent page placed through hospital operator to Dr. Patel, covering physician. Message included new confusion, BP 86/50, HR 124, RR 30, and SpO₂ 88% on room air; requested immediate bedside evaluation and callback to unit number. 14:03: No callback received." }, { "situation": "", "before": "Supervisor aware.", "after": "14:01: Rapid response activated for hypotension, hypoxemia, and new confusion. Charge nurse Elena Lopez, RN, notified and at bedside at 14:02. Rapid response team and Dr. Chen arrived at 14:04; findings and unanswered page reported." }, { "situation": "", "before": "Paged again. Still nothing.", "after": "14:03: Second contact attempt to Dr. Patel through approved secure messaging system. Sent current assessment and vital signs, requested immediate evaluation, and reported rapid response activation. 14:04: Message status displayed delivered; no reply or telephone callback received." }, { "situation": "", "before": "New orders received.", "after": "14:05: Dr. Chen evaluated patient at bedside and gave verbal order for 12-lead ECG now. Order read back and confirmed. 14:07: ECG obtained and reviewed at bedside by Dr. Chen." }, { "situation": "", "before": "Oxygen applied. Will continue to monitor.", "after": "14:02: Oxygen started at 2 L/min by nasal cannula under emergency oxygen protocol. 14:05: SpO₂ 94% on 2 L/min, RR 28/min with persistent accessory muscle use, BP 88/52, HR 120. Patient remains confused. Findings reported to Dr. Chen at bedside; rapid response team remains with patient." }, { "situation": "", "before": "Report given. Transferred to ICU.", "after": "14:20: Transferred to ICU with rapid response team per Dr. Chen’s order. BP 94/58, HR 116, RR 26, SpO₂ 94% on oxygen at 2 L/min by nasal cannula; remains confused. Bedside handoff accepted by Morgan Davis, RN. Reviewed deterioration timeline, interventions, response, and Dr. Chen’s evaluation and transfer order. Receiving RN informed that Dr. Patel had not returned contact attempts as of 14:20." } ], "words_to_avoid": [ { "wording": "MD aware", "why": "Does not establish who received what information or how.", "instead": "Provider’s name and role, time, communication method, findings communicated, and response." }, { "wording": "Provider ignored pages", "why": "Assigns intent you may not know.", "instead": "No callback or secure-message reply received as of 14:04." }, { "wording": "Provider refused", "why": "May confuse an unanswered message with an actual decision.", "instead": "The specific request declined, the response given, and your subsequent action." }, { "wording": "Called several times", "why": "Hides the timing, recipients, and results.", "instead": "A separate timed entry for each attempt." }, { "wording": "No new orders", "why": "Omits the conversation and follow-up plan.", "instead": "What was discussed, the provider’s instructions, and what happened next." }, { "wording": "Stable", "why": "Can obscure persistent abnormalities.", "instead": "Actual reassessment findings and comparison with the prior assessment." }, { "wording": "Will continue to monitor", "why": "Does not identify the checks or document completed reassessment.", "instead": "A specific monitoring plan followed by timed results and any further escalation." } ], "cases": [ { "case": "Adventist Healthcare v. Mattingly", "url": "https://www.courtlistener.com/opinion/10021230/adventist-healthcare-v-mattingly/", "court": "Court of Special Appeals of Maryland", "year": "2020", "quote": "", "what_it_shows": "The opinion describes a postoperative patient whose abdominal symptoms worsened, followed later by abnormal vital signs. His surgeon gave orders at first, then said he was coming. He had not arrived when the patient became unconscious. The claim against the hospital included an allegation that the nurse failed to escalate under hospital policy. A jury returned a verdict against the hospital and surgeon. The appellate court affirmed. It explained that the expert testimony, taken together with the other evidence, was enough to establish causation and let the claim go to the jury. The point here is the difference between contacting a provider and getting a response to a patient’s ongoing deterioration. It is not about a particular charting phrase." }, { "case": "Evans v. The Medical Center of Central Georgia", "url": "https://www.courtlistener.com/opinion/4896034/brandy-evans-v-the-medical-center-of-central-georgia-dba-the-medical/", "court": "Court of Appeals of Georgia", "year": "2021", "quote": "", "what_it_shows": "In this emergency-department case, the plaintiff’s experts pointed to an incomplete triage form, failures to communicate relevant findings, and failures to advocate for further evaluation among the alleged nursing shortcomings. The physician could not remember whether, before discharge, he had seen the report documenting some of the patient’s symptoms. The appellate court reversed summary judgment for the nurse and hospital because the evidence raised a factual question about causation. That was not a final finding of malpractice. For your documentation, the distinction matters: recording a symptom and communicating it are two separate things." } ], "guidance": [ { "says": "If the ordering or primary provider is unavailable or does not answer, follow the escalation pathway to another provider or supervisor. Don’t stop at an unanswered message.", "sources": [ { "name": "American Nurse", "url": "https://www.myamericannurse.com/nurse-spotlight-healthcare-documentation/" }, { "name": "The Health Law Firm", "url": "https://www.thehealthlawfirm.com/wp-content/uploads/2023/11/25-Legal-Tips-For-Nursing-Documentation.pdf" } ] }, { "says": "For urgent provider communication, use SBAR: the situation, relevant background, your assessment, and the action you are requesting.", "sources": [ { "name": "Inova", "url": "https://www.inova.org/sites/default/files/escalation-and-notification.pdf" }, { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "pulled-not-given", "title": "You pulled the medication but never gave it", "search_title": "You pulled the medication but never gave it", "question": "If I remove a controlled medication from the dispensing cabinet but the dose is canceled before administration, what should I enter in the MAR, and what belongs in the return or waste record?", "asked_as": "nurses canceled dose already pulled Pyxis not administered MAR return waste documentation allnurses reddit", "cluster": "trouble", "url": "https://shiftiswild.com/notes/pulled-not-given/", "markdown_url": "https://shiftiswild.com/notes/pulled-not-given.md", "summary": "You pull a controlled medication from the cabinet. Before you give it, the order is canceled. The MAR needs to show that the patient did **not** receive the dose. The return or waste record needs to show where the medication went.", "key_points": [ "Don't chart the dose as administered. Use your EHR’s appropriate nonadministration status and give the actual reason, such as the order being discontinued before administration.", "Account for the medication separately. Complete the approved return or waste transaction linked to the patient and the cabinet removal.", "Account for everything you removed. If nothing reached the patient, the administered amount is zero. The return or waste record must account for all unused medication, not just the intended dose.", "Follow your facility’s return, disposal, and verification process. Not sure whether you can return it? Secure it through the approved process and contact pharmacy or the charge nurse. Don't improvise disposal or ask someone to verify waste they didn't observe." ], "one_thing": "**The MAR shows what the patient did not receive. The return or waste record shows where the medication went.**", "what_goes_wrong": "The common mistake is treating the cabinet record and the MAR as if they document the same thing.\n\nA cabinet removal shows that medication left inventory. It doesn't show that you gave it. A nonadministration entry in the MAR explains what happened clinically, but it doesn't account for the medication you still have. Even if the systems are linked, these are separate events.\n\nThat leaves two common gaps:\n\n- The MAR says the dose wasn't given, but there's no completed return or waste record.\n- The medication was returned or wasted, but the MAR still says it was administered, or the dose entry is left unresolved.\n\nCanceling the order doesn't close either gap. You still need to document that the dose wasn't given and what happened to the medication. And choosing **held** or **patient refused** just to close the entry can give the wrong reason.", "rewrites": [ { "situation": "Canceled order; unopened tablet returned", "before": "0912 — Oxycodone 5 mg PO administered.", "after": "MAR: 0912 — Oxycodone 5 mg PO not administered. Order discontinued by J. Lee, MD, at 0910, before administration.\n\nReturn record: 0918 — Oxycodone 5 mg, 1 unopened unit-dose tablet returned to the ADC designated return bin using the return transaction linked to the 0905 removal." }, { "situation": "Canceled order; entire opened vial wasted", "before": "1022 — Morphine held. Wasted 1 mg.", "after": "MAR: 1022 — Morphine 1 mg IV not administered. Order discontinued at 1022 before administration.\n\nWaste record: 1026 — Morphine 2 mg/mL, 1 mL vial removed at 1020. Administered: 0 mg. Wasted: entire 2 mg, 1 mL, in the approved controlled-substance waste system. Waste observed and electronically verified by A. Patel, RN." }, { "situation": "Patient refusal; opened tablet wasted under facility policy", "before": "1110 — Patient refused. Med discarded.", "after": "MAR: 1110 — Oxycodone 5 mg PO not administered. Patient declined dose when offered.\n\nWaste record: 1114 — Oxycodone 5 mg, 1 opened unit-dose tablet wasted in the approved controlled-substance waste system; linked to the 1105 removal. Waste observed and electronically verified by M. Jones, RN." } ], "words_to_avoid": [ { "wording": "Given", "why": "Says the patient received the medication.", "instead": "Not administered, followed by the actual reason." }, { "wording": "Held", "why": "May suggest a temporary withholding rather than a canceled order.", "instead": "Order discontinued before administration, if accurate." }, { "wording": "Returned/wasted", "why": "Leaves two different dispositions unresolved.", "instead": "The single disposition that occurred, with amount, time, and destination or method." }, { "wording": "Med discarded", "why": "Does not identify the medication, quantity, or disposal process.", "instead": "Medication name, strength, quantity, and completed approved waste transaction." }, { "wording": "Wasted with Jane", "why": "A name in a comment does not replace required witness authentication.", "instead": "Complete the designated witness verification for the waste actually observed." } ], "cases": [ { "case": "Davis v. Louisiana State Board of Practical Nurse Examiners", "url": "https://www.courtlistener.com/opinion/1557145/davis-v-louisiana-state-board-of-practical-nurse-examiners/", "court": ", Louisiana Court of Appeal", "year": "2009", "quote": "", "what_it_shows": "The opinion describes complaints that included hydrocodone entries in the controlled-substance record with no corresponding MAR entries. The court upheld the Board’s license revocation based on a broader record involving multiple facilities and other practice concerns. This was not a canceled-dose case. You can't attribute the outcome to one documentation mismatch. The connection here is narrower: unless you complete both accurately, the controlled-substance record and the MAR can tell different stories." } ], "guidance": [], "ready_to_copy": "", "samples_are_written": true }, { "slug": "intrusive-thoughts", "title": "Charting Intrusive Thoughts of Self Harm or Harm to Others When There Is No Plan", "search_title": "Charting intrusive thoughts a patient reports", "question": "How do I chart a patient's intrusive thoughts of self harm or harming others when the patient denies plan, intent, or psychosis?", "asked_as": "nurse charting intrusive thoughts denies plan intent suicide harm others", "cluster": "trouble", "url": "https://shiftiswild.com/notes/intrusive-thoughts/", "markdown_url": "https://shiftiswild.com/notes/intrusive-thoughts.md", "summary": "A patient tells you about scary, unwanted thoughts of self-harm or hurting someone else. Then they clearly deny wanting to act on them. No plan. No intent. No psychotic symptoms.\nYour note still needs more than denies SI/HI. The next clinician needs the actual picture: what the patient said yes to, what they denied, what you saw, and what safety step is in place.", "key_points": [ "Chart the thought itself: self-harm or harm to others, intrusive or unwanted, image/thought/urge, frequency, trigger, and distress level.", "Keep the positives and negatives separate: endorsed intrusive thought, denies wish to die or harm, denies plan, intent, rehearsal, preparatory behavior, means/access, and command hallucinations.", "Do not chart denies SI/HI if the patient did report self-harm or harm thoughts. Chart denies active suicidal intent or homicidal intent instead.", "Add what you observed: calm or agitated, intoxicated or sober, responding to internal stimuli or not, cooperative or escalating.", "Chart what you did next: screening tool completed, provider/charge nurse notified if required, observation level, room safety steps, safety plan, coping plan, and whether the patient agrees to notify staff if thoughts worsen." ], "one_thing": "Chart the intrusive thought as present. Then chart plan, intent, means, psychosis, observations, and safety actions separately.", "what_goes_wrong": "The common mistake is a note that looks clean but does not say enough: denies SI/HI, intrusive thoughts, no plan. The wording is not the real problem. The problem is that the note jams two different findings into one line.\n\nIf the patient reports an intrusive thought of cutting, then denies SI is not quite right. They did report a self-harm thought. What they denied was wanting to die, intending to act, having a plan, having access to means, or having psychotic symptoms driving the thought.\n\nSame thing with harm-to-others thoughts. A patient can report an unwanted image of hitting someone and still deny homicidal intent. Your chart needs both parts: the intrusive content is present, and the desire, plan, intent, target behavior, weapon access, or command hallucinations are denied.", "rewrites": [ { "situation": "", "before": "Denies SI/HI. Intrusive thoughts noted. Will monitor.", "after": "1410 Patient reports recurrent unwanted thought of cutting forearm when anxiety increases. Reports thought is distressing and unwanted. Denies wish to die, suicide plan, intent, rehearsal, preparatory behavior, or access to sharps. Denies auditory or visual hallucinations and denies command hallucinations. No self-harm behavior observed this shift. Affect anxious, cooperative with assessment. Unit suicide screen completed per policy. Provider notified. q15 min checks maintained. Patient agrees to notify staff if urge, intent, or ability to stay safe changes." }, { "situation": "", "before": "Passive SI, no plan.", "after": "0930 Patient reports intermittent passive death wish on waking, lasting several minutes, without current desire to die. Denies active suicidal intent, plan, preparatory acts, or medication stockpiling. Denies hallucinations, paranoia, or belief that they must harm self. Thought process linear. Identifies sister and upcoming outpatient appointment as reasons to stay safe today. Safety plan reviewed. Patient verbalizes plan to use call light or approach staff if thoughts intensify." }, { "situation": "", "before": "Patient having thoughts of hurting roommate but denies HI.", "after": "1800 Patient reports intrusive image of punching roommate during conflict. Describes thought as unwanted and frightening. Denies desire to harm roommate, denies homicidal intent, plan, specific time/place, threats, recent assault, or weapon access. Denies command hallucinations. No threatening behavior observed; speech normal volume, remained seated, accepted redirection. Charge RN and provider updated per unit process. Patient moved to quiet area and agreed to notify staff before approaching roommate." }, { "situation": "", "before": "No psychosis. Contracts for safety.", "after": "Patient denies auditory hallucinations, visual hallucinations, command hallucinations, paranoia, or belief that self-harm is required. Not observed responding to internal stimuli. Reports intrusive unwanted image of self-harm but denies plan or intent. Safety plan reviewed with patient, including grounding exercise and notifying staff if thoughts become urges. Current observation level continued per order." }, { "situation": "", "before": "Pt anxious, says she might cut but would never do it.", "after": "1235 Patient tearful and anxious, rates anxiety 8/10. Reports intrusive urge to cut when overwhelmed. Denies wanting to die, denies intent to cut, denies plan, denies access to sharps on unit, and denies past 24-hour rehearsal or preparatory behavior. No wounds noted on visible skin. RN stayed with patient for de-escalation, offered PRN per MAR, and removed loose razor from belongings per unit policy. Provider notified. Patient reports anxiety decreased to 5/10 after intervention." }, { "situation": "", "before": "Intrusive thoughts of crashing car. Safe.", "after": "Patient reports unwanted image of swerving car into traffic while driving earlier today. Denies desire to die or harm others, denies plan, intent, impaired reality testing, intoxication, or command hallucinations. Currently inpatient; car keys secured with belongings. Calm, cooperative, future-oriented during assessment. Grounding technique practiced. Observation level unchanged after provider review." } ], "words_to_avoid": [ { "wording": "Denies SI/HI", "why": "Too broad when the patient actually endorsed self-harm or harm-to-others thoughts", "instead": "Reports intrusive self-harm thought; denies wish to die, plan, intent, rehearsal, and means" }, { "wording": "No plan or intent", "why": "True but incomplete by itself", "instead": "Denies plan, intent, preparatory behavior, rehearsal, access to means, and command hallucinations" }, { "wording": "Intrusive thoughts", "why": "Too vague without content", "instead": "Intrusive unwanted thought of cutting forearm; intrusive unwanted image of hitting roommate" }, { "wording": "Passive SI", "why": "Can mean different things to different clinicians", "instead": "Reports passive death wish; denies active suicidal intent, plan, or preparatory behavior" }, { "wording": "Contracts for safety", "why": "Vague and easy to overread", "instead": "Safety plan reviewed; patient agrees to notify staff by call light if urge or intent increases" }, { "wording": "No psychosis", "why": "Too global as a stand-alone nursing note", "instead": "Denies AH/VH, command hallucinations, paranoia; not observed responding to internal stimuli" }, { "wording": "Safe", "why": "A conclusion without the supporting facts", "instead": "No current plan or intent reported; observation level q15 min; provider notified; room safety check completed" }, { "wording": "Manipulative or attention-seeking", "why": "Judgmental and not clinically specific", "instead": "Patient requested staff presence three times in one hour; tearful; accepted coping coaching" }, { "wording": "HI denied", "why": "Can conflict with reported harm thoughts", "instead": "Reports intrusive harm thought; denies desire to harm, target-specific plan, intent, threats, or weapon access" } ], "cases": [], "guidance": [ { "says": "Ask directly about self-harm or suicide. Keep it calm and normalized. Then separate the thought from plan, intent, and immediate safety.", "sources": [ { "name": "NCBI Bookshelf", "url": "https://www.ncbi.nlm.nih.gov/books/NBK590042/" }, { "name": "Nurseslabs", "url": "https://nurseslabs.com/suicide-behaviors-nursing-care-plans/" } ] }, { "says": "Chart the specific safety findings, not just a risk label: whether ideation is present or denied, whether plan or intent is present or denied, and what observation or safety level is being used.", "sources": [ { "name": "ICANotes", "url": "https://www.icanotes.com/2018/02/16/10-things-every-psychiatric-nurses-progress-note/" }, { "name": "NurseChartingPro", "url": "https://nursechartingpro.com/guides/safety-assessment-charting" } ] }, { "says": "When inpatient self-harm risk is identified, chart the safety actions you actually took: observation level, removing hazards when indicated, or other unit safety measures.", "sources": [ { "name": "PMC", "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC8086389/" }, { "name": "NurseTogether", "url": "https://www.nursetogether.com/obsessive-compulsive-disorder-nursing-diagnosis-care-plan/" } ] }, { "says": "If the patient agrees to seek staff help, document the concrete behavior: safety plan reviewed, coping step used, and patient agrees to alert staff if thoughts become urges or intent.", "sources": [ { "name": "NurseChartingPro", "url": "https://nursechartingpro.com/guides/mental-emotional-status-charting" }, { "name": "allnurses", "url": "https://allnurses.com/need-help-charting-t361870/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "controlled-waste", "title": "Charting Controlled Substance Waste Clearly", "search_title": "How to document controlled substance waste", "question": "What should I document when only part of a controlled substance dose is given and the rest is wasted or returned?", "asked_as": "nurses forum charting narcotic waste witness partial dose Pyxis what to document", "cluster": "trouble", "url": "https://shiftiswild.com/notes/controlled-waste/", "markdown_url": "https://shiftiswild.com/notes/controlled-waste.md", "summary": "When the vial, syringe, cup, or tablet has more than the ordered dose, your note has to do two things: show what the patient got, and show where the rest went. That’s it. The cabinet, the MAR, and the waste or return record should line up.", "key_points": [ "Chart what you actually gave: medication, dose, route, time, and the patient assessment or response when your unit requires it.", "Deal with the leftover amount right away: wasted or returned, exact amount, where it went, and who witnessed it.", "Spell out the math: amount removed minus amount given equals amount wasted or returned.", "Don’t chart the full dose as given if the patient only received part of it.", "If the scan, Pyxis, Omnicell, or waste entry goes sideways, correct it with facts per facility policy and notify the right person. Don’t guess." ], "one_thing": "Chart the math: amount removed, amount given, amount wasted or returned, witness, and time.", "what_goes_wrong": "The usual problem is simple: the MAR says one thing, and the dispensing cabinet says another. A nurse pulls morphine 4 mg, gives 2 mg, but the MAR looks like 4 mg was given. Or the cabinet has no matching waste entry.\n\nThat gap matters. Controlled-substance tracking is built from separate steps: removal, administration, waste, return, and witness documentation. If one step is vague or missing, the chart no longer explains where the unused medication went.\n\nThe partial dose usually isn’t the problem. The missing trail is.", "rewrites": [ { "situation": "", "before": "Morphine given. Waste witnessed.", "after": "2310 Morphine sulfate 2 mg IV given via L forearm PIV for pain 8/10. Medication removed as 4 mg/1 mL vial. 2 mg administered; 2 mg wasted immediately in approved controlled-substance waste container with J. Smith, RN witness in Omnicell. Pain reassessed 2340, 4/10." }, { "situation": "", "before": "Dilaudid 0.5 mg given, rest wasted.", "after": "0145 Hydromorphone 0.5 mg IV slow push given via R hand PIV per order. Vial contained 1 mg/1 mL. Remaining 0.5 mg wasted at time of administration with M. Lopez, RN witness; waste documented in Pyxis. RR 16, patient awake and reports pain decreased from 9/10 to 5/10 at 0215." }, { "situation": "", "before": "Fentanyl wasted with nurse.", "after": "1022 Fentanyl 25 mcg IV administered for dressing change per order. 50 mcg/1 mL vial removed. 25 mcg administered; 25 mcg wasted in approved controlled-substance waste container with K. Patel, RN witness and ADC waste entry completed." }, { "situation": "", "before": "Oxy wasted later.", "after": "2040 Oxycodone oral solution 5 mg PO administered from 10 mg/10 mL unit-dose cup. Remaining 5 mg/5 mL wasted per unit controlled-substance waste process with A. Green, RN witness. Waste documented in MAR and ADC." }, { "situation": "", "before": "Returned unused med.", "after": "1335 Order changed before administration. Lorazepam 2 mg/mL vial removed but not opened and not administered. Intact vial returned to ADC return bin with transaction documented; charge RN notified per unit process." }, { "situation": "", "before": "Forgot to waste.", "after": "Late entry 0320 for 0110 medication administration: Hydromorphone 0.4 mg IV administered from 1 mg/mL vial. 0.6 mg was wasted at 0112 in approved controlled-substance waste container with T. Brown, RN witness, but ADC waste entry was not completed at that time. Charge RN and pharmacy notified at 0315; discrepancy correction completed per policy." }, { "situation": "", "before": "Barcode did not work, narc given.", "after": "0905 Barcode scan unsuccessful after two attempts; medication and patient verified per downtime scanning process. Morphine sulfate 1 mg IV given from 2 mg/1 mL syringe. Remaining 1 mg wasted immediately with L. Chen, RN witness; manual MAR entry and ADC waste documentation completed." } ], "words_to_avoid": [ { "wording": "Wasted", "why": "Too vague by itself", "instead": "2 mg wasted in approved controlled-substance waste container with witness name" }, { "wording": "Rest wasted", "why": "Does not show the math", "instead": "4 mg removed, 2 mg administered, 2 mg wasted" }, { "wording": "Full dose given", "why": "Wrong if the patient received only part", "instead": "Actual dose administered: 2 mg IV" }, { "wording": "Narc", "why": "Sloppy and nonspecific", "instead": "Medication name and dose, such as morphine sulfate 2 mg" }, { "wording": "Witnessed", "why": "Weak if it does not say who and what was witnessed", "instead": "Waste witnessed by J. Smith, RN at time of disposal" }, { "wording": "Returned", "why": "Unsafe wording if the package was opened or drawn up", "instead": "Intact unopened vial returned, or remaining dose wasted" }, { "wording": "Fixed in Pyxis", "why": "Does not explain the event", "instead": "ADC waste entry corrected at 0320; charge RN and pharmacy notified" }, { "wording": "Probably wasted", "why": "Guessing language", "instead": "If not verified, document facts and follow discrepancy process" }, { "wording": "Scanner failed", "why": "Incomplete without alternate process", "instead": "Barcode scan unsuccessful; patient and medication verified per downtime process" } ], "cases": [ { "case": "Commonwealth v. Amanda K. Berube", "url": "https://www.courtlistener.com/opinion/10362567/commonwealth-v-amanda-k-berube/", "court": "Massachusetts Appeals Court", "year": "2025", "quote": "If the entire contents of a vial were not used, the nurse was supposed to empty the unused contents into a secure container and submit a waste report witnessed by another nurse.", "what_it_shows": "The opinion described an automated dispenser, a morphine vial, charted administration, and no waste report for unused morphine. The court affirmed the conviction for possession of a class A substance." }, { "case": "Henning v. Avera McKennan", "url": "https://www.courtlistener.com/opinion/9507894/henning-v-avera-mckennan/", "court": "South Dakota Supreme Court", "year": "2020", "quote": "Avera McKennan Hospital terminated Stephanie Henning, a nurse in its intensive care unit, after it discovered errors in Henning’s documentation of controlled substances.", "what_it_shows": "The record described automated dispensing reports, scanning issues, and controlled substances that could not be accounted for. The court affirmed summary judgment for the hospital on the employment claims." }, { "case": "Laura Lee Demastus v. University Health System, Inc.", "url": "https://www.courtlistener.com/opinion/4372520/laura-lee-demastus-v-university-health-system-inc/", "court": "Court of Appeals of Tennessee", "year": "2017", "quote": "She, however, could not explain the suspicious transactions.", "what_it_shows": "The medication review compared Omnicell removals with patient charting and looked for doses that were not documented as administered or wasted. The court affirmed summary judgment for the employer." }, { "case": "Dana Casnocha-Jones v. State Board of Nursing", "url": "https://www.courtlistener.com/opinion/10631344/dana-casnocha-jones-v-state-board-of-nursing/", "court": "Missouri Court of Appeals", "year": "2024", "quote": "She would re-fill the vial with an identical amount of a saline solution, and would show the vial to another nurse, who would confirm that it contained the appropriate amount of residual liquid.", "what_it_shows": "The record shows why the waste witness needs to see the actual waste process, not just look at a container afterward." } ], "guidance": [ { "says": "Document the medication administration promptly in the MAR or EHR. Include the actual dose and route. Use barcode scanning when that is your facility’s process.", "sources": [ { "name": "Medical Solutions", "url": "https://www.medicalsolutions.com/blog/clinician/narcotic-waste/" }, { "name": "OpenStax", "url": "https://openstax.org/books/clinical-nursing-skills/pages/11-3-documentation-of-medication-administration" } ] }, { "says": "When you give only part of a controlled substance dose, document the leftover amount as waste through the automated dispensing cabinet or EHR with a witness. Follow your facility workflow.", "sources": [ { "name": "AHRQ PSNet", "url": "https://psnet.ahrq.gov/web-mm/multiple-high-risk-events-involving-workflow-wasting-medications-used-anesthesia" }, { "name": "WTCS Pressbooks", "url": "https://wtcs.pressbooks.pub/nursingskills/chapter/15-2-basic-concepts-of-administering-medications/" } ] }, { "says": "Use your facility’s approved controlled-substance disposal or return process. Don’t make up a workaround.", "sources": [ { "name": "Practice Greenhealth", "url": "https://practicegreenhealth.org/sites/default/files/2019-03/best_practices_for_disposal_of_controlled_substances_0_0.pdf" }, { "name": "eCFR", "url": "https://www.ecfr.gov/current/title-21/chapter-II/part-1317" } ] }, { "says": "Keep controlled-substance records consistent. Bad or mismatched charting can create medication-safety problems and diversion-monitoring concerns.", "sources": [ { "name": "NursingCenter", "url": "https://www.nursingcenter.com/upload/journals/documents/200303nsoce1risks.htm" }, { "name": "NCHA", "url": "https://www.ncha.org/wp-content/uploads/2018/06/Controlled-Substance-Diversion-Program-Structure.pdf" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "isolation-precautions", "title": "How to Chart Isolation Precautions Clearly", "search_title": "Documenting isolation precautions and refusals", "question": "What should I write when isolation precautions are started, changed, missed, or discontinued?", "asked_as": "nurses forum charting isolation precautions contact droplet airborne documentation", "cluster": "trouble", "url": "https://shiftiswild.com/notes/isolation-precautions/", "markdown_url": "https://shiftiswild.com/notes/isolation-precautions.md", "summary": "Isolation charting needs to show four things: when it happened, what type of precautions, why they were started, and what you did about it.\nThe easy parts are the checkboxes. The messy parts are starts, changes, missed steps, and stopping isolation.", "key_points": [ "Chart the exact time precautions were started, changed, missed, or discontinued.", "Name the precaution type: Contact, Droplet, Airborne, Contact Enteric, Protective, or your facility’s exact label.", "Chart the trigger: lab result, symptoms, provider order, infection prevention direction, facility protocol, or transfer report.", "Chart what you actually did: sign posted, PPE cart stocked, patient education, visitor instructions, room move, dedicated equipment, notifications.", "If something was missed, chart facts and fixes. Not blame." ], "one_thing": "Chart the isolation timeline: category, reason, actions, notifications, and what changed.", "what_goes_wrong": "The note I see all the time is this: Isolation started.\n\nThat does not help the next nurse. It does not say what kind of isolation. It does not say why it started, when it started, whether the room was ready, whether the patient or visitors got teaching, or who was told.\n\nSame problem on the back end. If precautions were missed and the note only says Precautions not followed, nobody can tell what actually happened. What was the risk window? Who was involved? What got fixed?\n\nYou do not need a novel. You need a clean trail another clinician can follow.", "rewrites": [ { "situation": "", "before": "Pt placed in isolation.", "after": "0835 Contact and Droplet Precautions initiated after RSV PCR resulted positive at 0828. Isolation sign posted, PPE cart stocked at doorway, dedicated stethoscope placed in room. Patient and mother instructed on hand hygiene, mask use for transport, and visitor PPE. Charge RN notified." }, { "situation": "", "before": "COVID precautions changed.", "after": "1410 Isolation updated from Droplet/Contact to Airborne/Contact per facility aerosol-generating procedure before nebulized treatment. Patient moved to AIIR room 412. N95, eye protection, gown, and glove signage posted. RT and charge RN notified. SpO2 95% on room air, no acute distress." }, { "situation": "", "before": "Rule out TB.", "after": "0720 Airborne Precautions initiated per provider order for rule out pulmonary TB after hemoptysis and abnormal chest imaging. Patient placed in negative-pressure room 606, door closed, N95 signage posted. Patient instructed to wear surgical mask for essential transport only. Charge RN notified." }, { "situation": "", "before": "Forgot to put sign up.", "after": "1015 Late entry for 0930: Contact Enteric Precautions ordered at 0902 for suspected C. difficile. At 0930, isolation sign was not posted and dedicated BP cuff was not in room. Sign posted, PPE cart placed, dedicated BP cuff obtained, soap-and-water hand hygiene reviewed with patient. Charge RN and infection prevention notified per unit process. Patient remained in room during 0902–0930 period." }, { "situation": "", "before": "Patient went to CT without isolation.", "after": "1245 Droplet Precautions order noted active since 1120. Patient transported to CT at 1205 before mask was applied. Patient returned to room at 1235 and mask removed once in room. Charge RN, CT lead, and infection prevention notified. Patient afebrile, RR 18, SpO2 97% on room air. Door sign and transport checklist reviewed." }, { "situation": "", "before": "Family noncompliant with PPE.", "after": "1905 Visitor at bedside without mask and gown while Contact/Droplet Precautions active. Visitor stated they did not see doorway sign. PPE instructions provided at doorway; visitor performed hand hygiene and donned mask and gown. Patient resting in bed, no distress. Charge RN notified." }, { "situation": "", "before": "Isolation DC’d.", "after": "1530 Contact/Droplet Precautions discontinued per ID note and facility isolation grid. Patient afebrile for greater than 24 hr, respiratory symptoms improved, no new oxygen need. Isolation banner updated, door sign removed, PPE cart removed, EVS notified for room cleaning. Patient instructed that standard hand hygiene continues." }, { "situation": "", "before": "Cleared by infection control.", "after": "0900 Airborne Precautions discontinued per infection prevention RN after review of negative test results and symptom timeline. Patient remains on Standard Precautions. Door sign removed, EHR isolation status updated, charge RN and EVS notified. Patient informed that mask is no longer required inside room unless otherwise directed." } ], "words_to_avoid": [ { "wording": "Isolation started", "why": "Missing category, time, reason, and setup steps", "instead": "Contact/Droplet Precautions initiated at 0835 for RSV PCR positive result; sign, PPE cart, dedicated equipment, and teaching completed" }, { "wording": "COVID precautions", "why": "Too broad; facilities use different categories", "instead": "Droplet/Contact, Airborne/Contact, or your facility’s exact isolation label" }, { "wording": "Noncompliant", "why": "Sounds like judgment and does not say what happened", "instead": "Visitor at bedside without mask; PPE instructions provided; visitor donned mask" }, { "wording": "Refused isolation", "why": "Patients usually do not refuse isolation itself; they may decline a piece of it", "instead": "Patient declined to keep door closed after education; charge RN notified" }, { "wording": "Exposed everyone", "why": "Overstates and does not document facts", "instead": "Patient transported to CT without mask from 1205–1235; charge RN, CT lead, and infection prevention notified" }, { "wording": "Forgot", "why": "Blame word; not useful clinically", "instead": "Precaution sign not posted when order reviewed at 0930; sign posted and PPE cart placed" }, { "wording": "Cleared", "why": "Too vague for discontinuation", "instead": "Precautions discontinued per infection prevention RN after criteria reviewed" }, { "wording": "Per policy", "why": "Fine as support, but weak by itself", "instead": "Per facility isolation protocol for suspected norovirus: Contact Enteric Precautions initiated" } ], "cases": [], "guidance": [ { "says": "Use Standard Precautions for every patient. Add Transmission-Based Precautions, like Contact, Droplet, or Airborne, when the organism, symptoms, or facility protocol call for it.", "sources": [ { "name": "CDC", "url": "https://www.cdc.gov/infection-control/hcp/isolation-precautions/index.html" }, { "name": "Lippincott NursingCenter", "url": "https://www.nursingcenter.com/getattachment/clinical-resources/nursing-pocket-cards/isolation-precautions/Pocket-Card-Isolation-Precautions_June-2025.pdf.aspx" } ] }, { "says": "Make the isolation category visible and consistent. Staff need to know what to do at the bedside, and the EHR needs to show when precautions were started, continued, and stopped.", "sources": [ { "name": "CDC Stacks", "url": "https://stacks.cdc.gov/view/cdc/23188/cdc_23188_DS1.pdf" }, { "name": "PMC", "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC3105328/" } ] }, { "says": "Do not stop precautions just because the patient looks better. Reassess based on the organism, time course, symptoms, test results, and your facility or infection prevention criteria.", "sources": [ { "name": "Lippincott NursingCenter", "url": "https://www.nursingcenter.com/getattachment/clinical-resources/nursing-pocket-cards/isolation-precautions/Pocket-Card-Isolation-Precautions_June-2025.pdf.aspx" }, { "name": "CDC", "url": "https://www.cdc.gov/infection-control/hcp/isolation-precautions/index.html" } ] }, { "says": "Keep transport out of the room to necessary care. When your facility policy calls for it, use source-control steps like masking or clean clothing.", "sources": [ { "name": "CDC", "url": "https://www.cdc.gov/infection-control/hcp/isolation-precautions/index.html" }, { "name": "Providence", "url": "https://www.providence.org/-/media/project/psjh/providence/wa/files/smmc/prep-portal/isolation-precautions-8720-5404.pdf?rev=53956c8fabf74b0aaa2f09536c5480bf&hash=93E28F2A39CB598ED2A000859014E405" } ] }, { "says": "If isolation status affects room cleaning or room logs, tell the responsible department. Then chart the clinical notification or status change in the right place.", "sources": [ { "name": "Providence", "url": "https://www.providence.org/-/media/project/psjh/providence/wa/files/smmc/prep-portal/isolation-precautions-8720-5404.pdf?rev=53956c8fabf74b0aaa2f09536c5480bf&hash=93E28F2A39CB598ED2A000859014E405" }, { "name": "NYC Health + Hospitals", "url": "https://ess.nychhc.org/uploads/Isolation-Guidelines.pdf" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "needlestick", "title": "You Got Stuck and the Clock Started", "search_title": "Needlestick at work: what to do and what to write down", "question": "What do I actually do — and write down — after a needlestick?", "asked_as": "needlestick nurse what to do report exposure hospital documentation", "cluster": "trouble", "url": "https://shiftiswild.com/notes/needlestick/", "markdown_url": "https://shiftiswild.com/notes/needlestick.md", "summary": "A needlestick gives you two jobs at once. Take care of the puncture now. Then get a clean factual note down while the details are still fresh. Don’t write a confession. Don’t guess. Don’t write a novel. Write what happened, what you did, who you told, and where follow-up is being handled.", "key_points": [ "Stop safely. Take off your gloves and wash the puncture or cut with soap and water.", "Tell charge nurse, your supervisor, and Employee Health or the ED exposure process right away.", "Don’t self-triage because you’re scared, embarrassed, know the source diagnosis, or don’t see blood.", "Chart facts: time, device, body site, glove/PPE, visible injury, source patient identifier per policy, first aid, notifications, and follow-up location.", "If you report late, don’t back-time anything. Make a late entry with the real event time and the real reporting time." ], "one_thing": "Do first aid. Report now. Chart the time, device, body site, source process, notifications, and follow-up. No guesses.", "what_goes_wrong": "The usual mistake is waiting because it looks small, feels embarrassing, or seems like it’s probably fine.\n\nThat delay causes two problems.\n\nFirst, the exposure workflow runs on time. Wound care, source-patient process, baseline labs, and possible medication evaluation all go better when they start early.\n\nSecond, your memory gets fuzzy fast. By the end of the shift, Needle stick, charge aware does not tell anyone what device was involved, whether the safety feature engaged, where the puncture was, whether there was visible blood, who was notified, or when Employee Health took over.\n\nThis is not about blaming yourself. It’s about giving the next person enough facts to keep going without guessing.", "rewrites": [ { "situation": "", "before": "Needle stick. Charge aware.", "after": "1427: During SQ insulin administration, after injection and before safety shield was fully engaged, used insulin pen needle punctured left index finger through glove. Removed glove and washed site with soap and water. No active bleeding noted. Charge RN J. Smith notified at 1432. Employee Health contacted at 1436 and instructed staff member to report for exposure evaluation. Patient remained stable; medication administered as ordered." }, { "situation": "", "before": "Got stuck by HCV+ patient. Freaking out.", "after": "2240: After venipuncture on source patient [MRN], used hollow-bore butterfly needle punctured right middle finger distal pad through glove while safety device was being activated. Small puncture with scant bleeding. Washed with soap and water at sink immediately. Charge RN notified 2243; house supervisor notified 2245; Employee Health/ED exposure protocol initiated 2250. Source patient information provided to Employee Health per facility policy." }, { "situation": "", "before": "Needle touched my glove but I do not think it went through. Probably fine.", "after": "0710: Used needle contacted right thumb glove during disposal. Removed glove and inspected glove and skin. No visible glove tear, puncture, bleeding, or skin break noted at that time. Washed hands with soap and water. Charge RN notified at 0718 for exposure screening per unit policy. Employee Health contacted at 0725 for guidance." }, { "situation": "", "before": "Late entry. Stuck yesterday and forgot to report.", "after": "Late entry entered 09/18/2026 at 0915. Event occurred 09/17/2026 at approximately 1830. While disposing of used insulin pen needle after medication administration, inner needle tip contacted left thumb after cap removal. No visible bleeding noted at time of event. Washed area immediately. Supervisor was not notified during shift. Charge RN and Employee Health notified today at 0900; exposure evaluation and incident report initiated." }, { "situation": "", "before": "Safety needle failed.", "after": "1012: During cleanup after IV start, safety feature on used IV catheter device did not fully cover needle tip after activation attempt. Exposed needle tip punctured left palm through glove when device was moved from procedure tray to sharps container. Washed puncture site with soap and water. Device secured and placed in sharps container after supervisor review per policy. Charge RN notified 1015; Employee Health notified 1018." } ], "words_to_avoid": [ { "wording": "Dirty needle", "why": "Emotional and imprecise", "instead": "Used needle; needle contaminated with blood/OPIM if known" }, { "wording": "Clean needle", "why": "Sounds like you reached a conclusion", "instead": "Unused sterile needle, or no visible blood noted" }, { "wording": "Probably fine", "why": "That’s a medical conclusion before evaluation", "instead": "Exposure evaluation pending; Employee Health notified" }, { "wording": "No risk", "why": "Says more than you know", "instead": "No visible puncture/bleeding noted; referred per protocol" }, { "wording": "Freaking out", "why": "Does not help the clinical picture", "instead": "Reports anxiety about exposure; Employee Health notified" }, { "wording": "My fault", "why": "Blame language, not facts", "instead": "Describe the mechanics of the event" }, { "wording": "Patient has HIV/HCV", "why": "Can put private source details in the wrong record", "instead": "Source patient information provided to Employee Health per policy" }, { "wording": "Safety failed", "why": "Too vague by itself", "instead": "Safety shield did not fully cover needle tip after activation attempt" } ], "cases": [ { "case": "Babich v. Waukesha Memorial Hospital, Inc.", "url": "https://www.courtlistener.com/opinion/1346456/babich-v-waukesha-memorial-hospital-inc/", "court": "Court of Appeals of Wisconsin", "year": "1996", "quote": "While Pamela Babich was a patient at Waukesha Memorial Hospital, Inc., she was stuck with a hypodermic needle that was mistakenly left in her bed linens.", "what_it_shows": "A patient was punctured by a needle left in hospital linens. The court’s discussion turned on what people knew, and did not know, about the needle and the possible source of contamination." }, { "case": "Barrett v. Danbury Hospital", "url": "https://www.courtlistener.com/opinion/7895992/barrett-v-danbury-hospital/", "court": "Supreme Court of Connecticut", "year": "1995", "quote": "failed to include the times the rectal exams were done and did not contain a description of the patient’s buttocks, particularly whether it was examined for fissures or scratches.", "what_it_shows": "This was a blood-exposure case, not a staff needlestick case. Still useful for charting habits. The record included an expert criticism that the chart missed timing and skin-condition details." }, { "case": "Becton Dickinson and Co. v. Usrey", "url": "https://www.courtlistener.com/opinion/2361429/becton-dickinson-and-co-v-usrey/", "court": "Court of Appeals of Texas", "year": "2001", "quote": "Reported the stick as shown by an accident report, medical record, or other record kept at or within a reasonable time after the stick occurred.", "what_it_shows": "This case involved Texas health care workers who had needlesticks and sought reimbursement for post-needlestick testing costs. The proposed class definition partly depended on whether the stick was recorded close to when it happened." } ], "guidance": [ { "says": "For a needlestick or cut, wash the site with soap and water before you move on to paperwork.", "sources": [ { "name": "AMN Healthcare", "url": "https://www.amnhealthcare.com/blog/allied/travel/what-to-do-before-and-after-a-needlestick-injury/" }, { "name": "Wayne State University School of Medicine", "url": "https://www.med.wayne.edu/students/injury-protocol" } ] }, { "says": "Report the exposure through your workplace process promptly so evaluation and required injury tracking can happen when the sharp was contaminated with blood or other potentially infectious material.", "sources": [ { "name": "OSHA", "url": "https://www.osha.gov/laws-regs/regulations/standardnumber/1904/1904.8" }, { "name": "My CPR Certification Online", "url": "https://www.mycprcertificationonline.com/courses/bloodborne-pathogens/needlestick-injury" } ] }, { "says": "Don’t recap a used needle with two hands. Use the device safety feature and sharps-disposal process instead.", "sources": [ { "name": "NCBI Bookshelf", "url": "https://www.ncbi.nlm.nih.gov/books/NBK593214/table/ch18adminprntlmeds.T.guidelines_for_prev/" }, { "name": "Quizlet", "url": "https://quizlet.com/explanations/questions/which-nursing-intervention-is-done-to-prevent-needlestick-injuries-after-intravenous-administration-638412f4-44dc887d-072c-4855-9677-2388a0098551" } ] } ], "ready_to_copy": "[DATE] [TIME]: During [PROCEDURE/MEDICATION], care was paused due to staff sharps injury. Patient remained [PATIENT CONDITION]. [MEDICATION/PROCEDURE STATUS]. Patient safety maintained by [ACTION TAKEN]. Care continued by [NAME], [ROLE], at [TIME]. Charge RN [NAME] notified.", "samples_are_written": true }, { "slug": "workplace-violence", "title": "When a patient hits you and the shift keeps going", "search_title": "A patient assaulted you: reporting and documenting it", "question": "A patient assaulted me. What has to be written, and by whom?", "asked_as": "patient hit nurse assault workplace violence report hospital documentation", "cluster": "trouble", "url": "https://shiftiswild.com/notes/workplace-violence/", "markdown_url": "https://shiftiswild.com/notes/workplace-violence.md", "summary": "First, keep people safe and keep caring for the patient. Then get the event into the right records, by the right people, while everybody still remembers the details.", "key_points": [ "The patient chart gets patient-care facts: what the patient did, what staff did next, assessment, interventions, notifications, and the care plan.", "The workplace violence or incident report gets the staff-safety event: who was hit, where, how, witnesses, security response, and follow-up.", "Employee Health, or whoever treats you, documents your injury assessment in your employee/medical record. Not in the patient’s chart.", "The charge nurse or supervisor documents the operational response: coverage, reassignment, security, debrief, staffing changes, and safety plan.", "A police report, if made, does not replace the nursing note, the workplace violence report, or Employee Health documentation." ], "one_thing": "Put patient care in the chart. Put staff injury in the employee process. Put the safety event in the workplace violence report.", "what_goes_wrong": "The common mistake is one vague line in the chart and thinking that covers it.\n\nExample: Patient assaulted RN. Security notified.\n\nIt doesn’t. That line does not say what the patient actually did. It does not say whether the patient was assessed, what changed in the plan of care, who saw it, whether the injured staff member was relieved, or whether the workplace violence process started.\n\nIt also mixes two jobs. The patient chart is for patient care. The workplace violence report is for staff safety and facility follow-up. Employee Health documents the staff injury. Blur those records, or skip one, and the next shift has less to work with. The supervisor has less to act on. And the injured worker may have to rebuild the whole thing from memory later.", "rewrites": [ { "situation": "", "before": "Patient assaulted me.", "after": "At 1914, during medication administration, patient struck this RN on the left upper arm with right closed fist x1. This RN stepped back and called for staff assist. Charge RN and security arrived at 1915. Patient remained standing at bedside, yelling, and did not fall. Provider notified at 1918." }, { "situation": "", "before": "Patient became violent and unsafe.", "after": "At 2230, during hygiene care, patient kicked toward MHT with right leg x2 and contacted MHT’s left thigh x1. Care paused. Two staff remained at doorway. Patient was offered gown change or bath wipes later. Patient accepted bath wipes at 2245." }, { "situation": "", "before": "Crazy patient punched nurse for no reason.", "after": "At 0710, patient was sitting on edge of bed. This RN reached toward bedside table to move water cup. Patient swung right fist and contacted this RN’s left forearm x1. No staff physical contact with patient occurred immediately before the strike." }, { "situation": "", "before": "Security called. Incident report done.", "after": "At 1442, security arrived to room 412 after staff assist call. Patient was moved away from doorway with verbal direction. Bed placed in low position. Patient assessed by RN Lee at 1448. Provider Patel notified at 1450. Workplace violence report completed per facility process outside the medical record." }, { "situation": "", "before": "No injury.", "after": "Patient denied pain and no visible injury to patient noted after event. This RN reported left wrist pain after being struck and was relieved by RN Carter at 1035 to report to Employee Health." }, { "situation": "", "before": "Patient kept refusing to calm down.", "after": "From 1605 to 1615, patient yelled, paced between bed and door, and clenched fists. Patient did not respond to verbal redirection x3. Staff moved other patients away from hallway. Provider notified at 1616." } ], "words_to_avoid": [ { "wording": "`assaulted` in the patient chart", "why": "It is a conclusion. It does not describe the behavior.", "instead": "`patient struck RN on left forearm with closed fist x1`" }, { "wording": "`violent`", "why": "Too broad. The next shift cannot picture the risk.", "instead": "`kicked toward staff`, `spit toward staff`, `threw call light`" }, { "wording": "`crazy`, `psychotic`, `manipulative`", "why": "Labels do not document the event.", "instead": "Observable behavior and current assessment" }, { "wording": "`unprovoked`", "why": "It sounds like you know motive or cause.", "instead": "`No staff contact observed immediately before event`" }, { "wording": "`refused to calm down`", "why": "Vague and judgmental.", "instead": "`continued yelling after verbal redirection x3`" }, { "wording": "`no injury`", "why": "May ignore staff injury or lack of full assessment.", "instead": "`No visible patient injury noted`; document staff symptoms in employee process" }, { "wording": "`incident report completed` as the whole note", "why": "It does not document patient care.", "instead": "Chart assessment, interventions, notifications, and care plan changes" } ], "cases": [ { "case": "Cedar Springs Hospital v. Occupational Health and Safety", "url": "https://www.courtlistener.com/opinion/10793808/cedar-springs-hospital-v-occupational-health-and-safety/", "court": "Court of Appeals for the Tenth Circuit", "year": "2026", "quote": "", "what_it_shows": "The opinion involved workplace violence at a psychiatric hospital. One listed safety measure was: “Investigate and debrief after each incident of workplace violence”" }, { "case": "UHS of Delaware, Inc. v. Secretary of Labor", "url": "https://www.courtlistener.com/opinion/10610019/uhs-of-delaware-inc-v-secretary-of-labor/", "court": "Court of Appeals for the Eleventh Circuit", "year": "2025", "quote": "", "what_it_shows": "The citation discussed in the opinion included: “Conduct an investigation and debriefing after each act of workplace violence with the attacked and/or injured employee and other involved employees, including root cause or similar analysis, lessons learned, and corrective actions to prevent reoccurrence.”" }, { "case": "Maryland Aviation Administration v. Noland", "url": "https://www.courtlistener.com/opinion/1903290/maryland-aviation-administration-v-noland/", "court": "Court of Appeals of Maryland", "year": "2005", "quote": "", "what_it_shows": "After an incident involving a combative psychiatric patient, the court noted that reports “did not include any statements regarding the Employee’s act of twice striking the Patient.”" } ], "guidance": [ { "says": "Report the event promptly to a supervisor, manager, or security through the facility process. Don’t rely only on hallway conversation.", "sources": [ { "name": "Verve College", "url": "https://vervecollege.edu/nurse-assaulted-by-patient/" }, { "name": "Nursa", "url": "https://nursa.com/blog/heres-how-to-handle-patient-violence-against-nurses" } ] }, { "says": "Write the facts while they are fresh: time, place, observed behavior, actions taken, and who was notified.", "sources": [ { "name": "Verve College", "url": "https://vervecollege.edu/nurse-assaulted-by-patient/" }, { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" } ] }, { "says": "Keep clinical charting factual and specific. Skip opinions, labels, and vague summaries.", "sources": [ { "name": "nurse.com", "url": "https://www.nurse.com/blog/protect-yourself-with-tips-proper-documentation/" }, { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" } ] } ], "ready_to_copy": "[DATE] [TIME] Nursing note. During [CARE ACTIVITY], patient [PATIENT NAME OR IDENTIFIER] [SPECIFIC ACTION, BODY PART USED, NUMBER OF TIMES, BODY AREA CONTACTED]. This RN [STEPPED BACK / CALLED STAFF ASSIST / LEFT ROOM / ACTIVATED ALARM] at [TIME]. [NAME/TITLE] arrived at [TIME]. Patient response after event: [OBSERVED BEHAVIOR]. Patient assessment: [PAIN / INJURY / VITAL SIGNS / MENTAL STATUS / NO VISIBLE INJURY NOTED]. Interventions completed: [DE-ESCALATION / MEDICATION GIVEN WITH ORDER / SECURITY PRESENT / ROOM CHANGE / OBSERVATION LEVEL / RESTRAINT OR SECLUSION ORDER IF APPLICABLE]. Provider [NAME] notified at [TIME]; response/orders: [ORDERS OR NO NEW ORDERS]. Charge RN [NAME] notified at [TIME]. Care transferred to [NAME/TITLE] at [TIME] for staff safety and continuity of care.", "samples_are_written": true }, { "slug": "injury-on-duty", "title": "You got hurt on shift and waited a week to say anything", "search_title": "Hurt at work: reporting an injury on duty and the deadline", "question": "I got hurt on shift. How late is too late to report it?", "asked_as": "nurse injured at work report late workers compensation hospital", "cluster": "trouble", "url": "https://shiftiswild.com/notes/injury-on-duty/", "markdown_url": "https://shiftiswild.com/notes/injury-on-duty.md", "summary": "A week late is not great. Still, waiting longer will not fix it. Report it now. Use today’s date for the report, list the real date and time of the event, and stick to facts. Do not try to argue the whole case in the note.", "key_points": [ "Report the injury now through your employee injury, occupational health, or supervisor process.", "Do not backdate anything. Date the report today and list the actual date and time of the event.", "Write what happened, where it happened, what body part was affected, symptoms then, symptoms now, and who was present.", "If you mentioned it to anyone on shift, name that person and what you told them.", "Keep the patient chart about patient care. Put your injury in the employee injury system." ], "one_thing": "Report it now. Date it honestly. Write the event like a camera saw it.", "what_goes_wrong": "Reporting late is not the only problem. Reporting late and being vague is the problem.\n\nA note that says hurt my back last week gives occupational health, your manager, or the claim reviewer almost nothing to check. They cannot tell which patient, which room, which transfer, what you felt at the time, whether anyone saw it, or whether something else happened between then and now.\n\nDo not write a long emotional explanation. Write a clean timeline:\n\n- event date and approximate time\n- unit, room, task, and patient-care activity\n- body mechanics or exposure details\n- first symptom and current symptom\n- who was present or notified\n- why the report is being entered today, stated plainly\n\nLate does not mean false. But once it is late, the report has to be more precise, not less.", "rewrites": [ { "situation": "", "before": "Hurt my back last week. Reporting now.", "after": "Late employee injury report entered 09/18/2026 at 1430 for event on 09/11/2026 at approximately 2215. While assisting Patient [INITIALS/ROOM PER POLICY] from bed to chair in Room 412 with gait belt, patient knees buckled. I supported patient until CNA [NAME] assisted. I felt sudden pulling pain in low back at that time. Initial pain 4/10. Current pain 6/10 with bending. Charge RN [NAME] was notified today at 1415." }, { "situation": "", "before": "Patient grabbed me but I was okay.", "after": "Late employee injury report entered 09/18/2026 at 0935 for event on 09/12/2026 at approximately 0200 in ED Room 8. During redirection, patient reached with right hand and gripped my left wrist for approximately 5 seconds. Security and RN [NAME] entered room. Redness noted to left wrist after event. No report completed before end of shift. Current symptoms include soreness to left wrist with rotation, 3/10." }, { "situation": "", "before": "Maybe had a needlestick Friday. Not sure.", "after": "Employee exposure report entered 09/18/2026 at 1010 for possible exposure on 09/13/2026 at approximately 1845. While disposing of used insulin syringe after administration, needle contacted outer surface of right index-finger glove. After glove removal, I noted no visible puncture and no bleeding. Washed hands immediately. I did not complete exposure report that shift. Reporting now for occupational health review." }, { "situation": "", "before": "Shoulder has been messed up since we were short.", "after": "Late employee injury report entered 09/18/2026 at 1700 for event on 09/10/2026 at approximately 0630. While repositioning Patient [INITIALS/ROOM PER POLICY] up in bed with draw sheet and RN [NAME], I felt pulling pain in right shoulder. Two staff were at bedside. Portable lift was not in room. Initial pain 3/10 right shoulder. Current pain 5/10 with overhead movement." }, { "situation": "", "before": "I told people already.", "after": "Late employee injury report entered 09/18/2026 at 1205 for event on 09/11/2026 at approximately 2310. During transfer in Room 510, I felt a pop in low back. At approximately 2320, I told charge RN [NAME] that my back started hurting during the transfer. No employee injury report was completed that shift. Current symptoms are low back pain 6/10 and stiffness after sitting." } ], "words_to_avoid": [ { "wording": "I am fine", "why": "Closes the symptom trail too early", "instead": "No visible injury noted at [TIME]; reports [SYMPTOM] [SCORE]/10" }, { "wording": "No big deal", "why": "Minimizes before evaluation", "instead": "Initial symptoms were [SYMPTOMS]; current symptoms are [SYMPTOMS]" }, { "wording": "I think it happened sometime last week", "why": "Too hard to verify", "instead": "Symptoms began during [TASK] on [DATE] at approximately [TIME]" }, { "wording": "I forgot to report", "why": "Makes the delay the whole story", "instead": "No employee injury report was completed that shift; report entered today at [TIME]" }, { "wording": "Patient attacked me", "why": "Conclusion without mechanics", "instead": "Patient [GRABBED/PUNCHED/KICKED/SCRATCHED] my [BODY PART] at [TIME]" }, { "wording": "Unsafe staffing caused it", "why": "Argument instead of facts", "instead": "[NUMBER] staff were at bedside; [EQUIPMENT/HELP] was requested at [TIME]" }, { "wording": "Probably from work", "why": "Speculation", "instead": "Symptoms began immediately after [EVENT/TASK]" }, { "wording": "Everyone knows", "why": "No witness trail", "instead": "[NAME], [ROLE], was present or notified at [TIME]" }, { "wording": "I worked through it", "why": "Does not describe injury", "instead": "Continued shift after event; pain increased from [SCORE] to [SCORE] by [TIME]" } ], "cases": [ { "case": "Cawthorn v. Mission Hospital, Inc.", "url": "https://www.courtlistener.com/opinion/2502597/cawthorn-v-mission-hospital-inc/", "court": "Court of Appeals of North Carolina", "year": "2011", "quote": "", "what_it_shows": "A registered nurse reported a back injury to her supervisor the next morning, completed the hospital computerized injury report, and was sent to staff health. The court affirmed the award of benefits." }, { "case": "Dendy v. North Carolina Baptist Hospital", "url": "https://www.courtlistener.com/opinion/3890040/dendy-v-north-carolina-baptist-hospital/", "court": "North Carolina Industrial Commission", "year": "2007", "quote": "", "what_it_shows": "A CNA later described a laundry-related incident, but the occurrence report did not describe that incident, and the Commission found the January incident account not credible." }, { "case": "Hoffman, Lindsey v. HCA Health Services of Tennessee, Inc., dba TriStar Summit Medical Center", "url": "https://www.courtlistener.com/opinion/10652345/hoffman-lindsey-v-hca-health-services-of-tennessee-inc-dba-tristar/", "court": "Tennessee Workers Compensation Appeals Board", "year": "2025", "quote": "", "what_it_shows": "A hospital pharmacist reported safety events in internal reporting portals, but not through the employee injury portal. The Appeals Board affirmed the trial court decision that she was unlikely to prevail on timely notice at that stage." }, { "case": "Mitchell, Sebastian v. AECOM dba Shimmick Construction, Inc.", "url": "https://www.courtlistener.com/opinion/4985017/mitchell-sebastian-v-aecom-dba-shimmick-construction-inc/", "court": "Tennessee Workers Compensation Appeals Board", "year": "2021", "quote": "", "what_it_shows": "The worker did not give timely notice after learning the hand infection was tied to a work cut, but the employer did not show prejudice from the late notice. The award of some medical benefits was affirmed." }, { "case": "Kade Michael Woodell v. Alaska Regional Hospital", "url": "https://www.courtlistener.com/opinion/10674390/kade-michael-woodell-v-alaska-regional-hospital/", "court": "Alaska Supreme Court", "year": "2025", "quote": "", "what_it_shows": "A nurse alleged workplace exposure to C. diff and testified that he reported the exposure to a charge nurse shortly after it happened. The Alaska Supreme Court remanded for reinstatement of the 2020 compensation award." } ], "guidance": [ { "says": "Report and document as soon as you can. Waiting makes details easier to lose and harder to verify.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Are-You-Filing-Incident-Reports-Properly" }, { "name": "Nurse.org", "url": "https://nurse.org/news/nursing-documentation-mistakes/" } ] }, { "says": "If documentation is late, say so. Make the timing clear, and include who wrote it and when it was written.", "sources": [ { "name": "nurse.com", "url": "https://www.nurse.com/blog/is-it-legal-to-go-back-and-finish-documenting-on-a-patient-a-day-or-even-a-week-later/" }, { "name": "Berxi", "url": "https://www.berxi.com/resources/articles/nurse-charting-101/" } ] }, { "says": "Use concrete, relevant facts instead of generic wording. Vague or incomplete notes are weak notes.", "sources": [ { "name": "PMC", "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC9183775/" }, { "name": "TextExpander", "url": "https://textexpander.com/blog/examples-of-nursing-documentation-errors" } ] } ], "ready_to_copy": "[DATE] [TIME]\n\nHi [NAME], I am reporting a work injury now.\n\nOn [EVENT DATE] at approximately [EVENT TIME], while working on [UNIT/LOCATION], [WHAT HAPPENED]. I first noticed [INITIAL SYMPTOMS] at [TIME]. Current symptoms are [CURRENT SYMPTOMS].\n\nPeople present or notified at the time were [NAMES AND ROLES]. I did not complete an employee injury report before leaving that shift. I am completing the employee injury and occupational health process now.\n\n[YOUR NAME], [CREDENTIALS]", "samples_are_written": true }, { "slug": "how-the-hospital-protects-itself", "title": "When Risk Management Calls You In to Just Talk", "search_title": "Risk management asked to talk: what that meeting is", "question": "When they call me in to 'just talk', whose side is that meeting on?", "asked_as": "risk management nurse meeting peer review privilege hospital attorney", "cluster": "trouble", "url": "https://shiftiswild.com/notes/how-the-hospital-protects-itself/", "markdown_url": "https://shiftiswild.com/notes/how-the-hospital-protects-itself.md", "summary": "If risk management calls, start here: this is a facility process. That does not mean they are against you. It also does not mean they are your private advocate, therapist, or personal representative.", "key_points": [ "Risk management works for the organization. Their lane is usually patient safety, claims prevention, insurance, reporting, and fact-gathering.", "Before the meeting, ask what it is for, who will be there, and whether this is risk, quality, HR, or legal preparation.", "In the meeting, stay with what you personally remember and what the chart backs up. If you do not remember, say so.", "Do not use the patient chart to document the risk meeting, the incident report, or how you feel about blame.", "If an attorney is involved, ask what their role is before discussing patient facts outside the approved facility process." ], "one_thing": "Risk management is not automatically against you. It works for the organization. Keep your documentation factual, patient-focused, and away from self-defense.", "what_goes_wrong": "The usual mistake is treating the meeting like a casual vent session. Or a confession booth. People start filling gaps, explaining motives, blaming other staff, or writing a late chart note that reads like self-defense.\n\nThe route matters. Risk management may be gathering facts for quality review, patient safety follow-up, insurance, a claim file, regulatory reporting, or legal preparation. Those lanes are not the patient’s medical record.\n\nYour chart should show patient care: assessment, interventions, notifications, response, and follow-up. Keep the risk conversation out of it. Do not turn it into a second, emotional chart.", "rewrites": [ { "situation": "", "before": "Patient fell. Incident report done. Risk notified.", "after": "1032 Patient found sitting on floor on right side of bed. Patient awake and oriented to name and place. Reports right hip pain 5/10. No visible bleeding noted. VS: BP [BP], HR [HR], RR [RR], SpO2 [SPO2] on [O2]. Assisted back to bed with [STAFF]. Bed placed low, wheels locked, nonskid socks on, bed alarm activated. 1040 [PROVIDER NAME] notified; order received for [ORDERS]." }, { "situation": "", "before": "Doctor ignored my concerns about low BP.", "after": "2118 BP 82/46, MAP 58, HR 118. Skin cool and dry. Patient reports dizziness while lying in bed. 2120 [PROVIDER NAME] notified by secure message of BP, HR, symptoms, and current IV fluids. Requested bedside evaluation. 2127 [PROVIDER NAME] returned call; order received for NS bolus 500 mL and lactate. Bolus started 2130." }, { "situation": "", "before": "Previous shift did not monitor the IV and now it is infiltrated.", "after": "1905 On initial assessment, left forearm PIV site swollen approximately 4 cm, cool to touch. Patient reports pain 6/10 at site during infusion. Infusion stopped. PIV removed, catheter intact. Arm elevated. 1915 Charge RN [NAME] notified. New PIV placed right hand at 1930." }, { "situation": "", "before": "I made a med error because staffing was unsafe.", "after": "0900 Scheduled cefazolin not available in Pyxis. 0903 Pharmacy notified of missing dose. 0942 Dose delivered to unit. 0945 Cefazolin administered IV per MAR. Patient tolerated without adverse reaction. [PROVIDER NAME] notified of delayed administration at [TIME]." }, { "situation": "", "before": "Per risk management, adding details to protect myself.", "after": "Late entry for [DATE] [TIME]. Entry made on [DATE] at [TIME]. At [TIME], patient [ASSESSMENT FINDINGS]. [INTERVENTION] performed. [PROVIDER/CHARGE RN] notified at [TIME]. Patient response: [RESPONSE]." }, { "situation": "", "before": "Patient claims someone yanked out the Foley.", "after": "1510 Foley catheter noted out of patient with balloon deflated in bed. Small amount of blood noted at meatus. Patient reports catheter came out while standing to transfer to chair. VS: [VS]. Perineal care provided. [PROVIDER NAME] notified at [TIME]. Order received to [ORDER]." }, { "situation": "", "before": "Family was angry and accused staff of neglect.", "after": "1645 Patient’s daughter [NAME] at bedside requesting update on fall precautions and plan of care. Reviewed current interventions: bed alarm on, call light in reach, bed low, nonskid socks on, hourly rounding. Daughter requested provider update. [PROVIDER NAME] notified at 1655." }, { "situation": "", "before": "Everything was fine after the event.", "after": "1430 Reassessment after [EVENT]: patient awake, follows commands, denies chest pain, denies shortness of breath, pain 2/10 at [LOCATION]. VS: [VS]. Dressing clean/dry/intact. No new swelling or bleeding noted. Will continue [MONITORING PLAN]." } ], "words_to_avoid": [ { "wording": "Incident report completed", "why": "It drags the internal risk process into the patient chart", "instead": "Patient assessment, interventions, notifications, response" }, { "wording": "Risk management told me to add", "why": "It makes the note about legal/process activity, not care", "instead": "Late entry with date, time, and factual care details" }, { "wording": "Negligence, malpractice, unsafe care", "why": "Legal conclusions do not belong in a bedside note", "instead": "What you saw, did, reported, and monitored" }, { "wording": "Ignored", "why": "You are assuming intent", "instead": "Notified at [TIME]; response received at [TIME]; escalated to [NAME] at [TIME]" }, { "wording": "Refused to help", "why": "Personal and vague", "instead": "[NAME/TITLE] notified; no new orders received by [TIME]; charge RN notified" }, { "wording": "Obviously, clearly, due to", "why": "You are turning sequence into causation", "instead": "Patient found, patient stated, assessment showed" }, { "wording": "My fault, not my fault", "why": "Self-judgment instead of patient facts", "instead": "Medication given at [TIME]; provider notified; patient monitored" }, { "wording": "Covering myself", "why": "It never belongs in a clinical note", "instead": "Omit it" }, { "wording": "Patient was okay", "why": "Too vague for the next clinician", "instead": "Specific assessment findings and vital signs" }, { "wording": "Family was crazy, hostile, dramatic", "why": "Labels people instead of documenting behavior", "instead": "Family member [NAME] raised voice, requested [REQUEST], security notified if applicable" } ], "cases": [ { "case": "Nielson v. SwedishAmerican Hospital", "url": "https://www.courtlistener.com/opinion/4420844/nielson-v-swedishamerican-hospital/", "court": "Appellate Court of Illinois", "year": "2017", "quote": "", "what_it_shows": "Three nurses wrote quality control reports after a surgical injury. The reports went through risk management and later ended up in a discovery fight in litigation. The decision text described a hospital policy stating that a “QCR may serve as a report to legal counsel to assist in the defense of a lawsuit or claim.”" }, { "case": "Grosshuesch v. Edward Hospital", "url": "https://www.courtlistener.com/opinion/4437987/grosshuesch-v-edward-hospital/", "court": "Appellate Court of Illinois", "year": "2017", "quote": "", "what_it_shows": "Notes created through a hospital quality review process were disputed in discovery. The appellate court stated: “all the documents at issue should be produced.”" }, { "case": "Kolb v. Northside Hospital", "url": "https://www.courtlistener.com/opinion/4405963/kolb-v-northside-hospital/", "court": "Court of Appeals of Georgia", "year": "2017", "quote": "", "what_it_shows": "This was physician peer review, not nursing charting. Still worth remembering. Hospital review processes can involve staff reports, committees, written findings, attorneys, and formal next steps." } ], "guidance": [ { "says": "Keep the incident or event report separate from the patient’s medical record. In the chart, write the patient’s condition and care, not that a risk report was completed.", "sources": [ { "name": "MyLearningCommunity", "url": "https://www.mylearningcommunity.com/online_learning/custom/cctc/cgs09risk/media/CGSrisk.pdf" }, { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" } ] }, { "says": "Treat charting as both a care communication tool and a risk-management tool. Make it accurate, factual, and useful to the next clinician.", "sources": [ { "name": "Berxi", "url": "https://www.berxi.com/resources/articles/risk-management-in-nursing-tips/" }, { "name": "CareerStaff", "url": "https://www.careerstaff.com/clinician-life-blog/nursing/charting-in-nursing-dos-and-donts/" } ] }, { "says": "When you document care-related communication, give the parts that matter: who was notified, what information was shared, and what happened next.", "sources": [ { "name": "CM&F Group", "url": "https://www.cmfgroup.com/blog/nurses/nursing-documentation-mistakes-license-risk/" }, { "name": "RNpedia", "url": "https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/communication-and-documentation/" } ] } ], "ready_to_copy": "[DATE] [TIME] Patient [OBJECTIVE DESCRIPTION OF WHAT HAPPENED]. Patient found [LOCATION/POSITION]. Assessment: alertness/orientation [FINDINGS], pain [SCORE/LOCATION], skin [FINDINGS], bleeding [YES/NO AND LOCATION], movement/sensation [FINDINGS], VS [VITAL SIGNS]. Interventions performed: [INTERVENTIONS]. Safety measures in place: [BED LOW/WHEELS LOCKED/CALL LIGHT/BED ALARM/NONSKID SOCKS/OTHER]. [PROVIDER NAME/TITLE] notified at [TIME] of [KEY FACTS]. Orders received: [ORDERS OR NO NEW ORDERS]. Patient response after interventions: [RESPONSE]. Plan: [MONITORING/FOLLOW-UP].", "samples_are_written": true }, { "slug": "med-not-on-mar", "title": "When the Medication Is Not on the MAR", "search_title": "", "question": "What should I document when I find that a patient received or may have received a medication that is not on the MAR or has no active order?", "asked_as": "nurse discovered medication given not on MAR no order what to chart", "cluster": "trouble", "url": "https://shiftiswild.com/notes/med-not-on-mar/", "markdown_url": "https://shiftiswild.com/notes/med-not-on-mar.md", "summary": "You find out a patient got, or may have gotten, a medication that is not on the MAR. Maybe it was pulled. Maybe it was opened. Maybe it is sitting at the bedside. Maybe the patient says they took it. Maybe it came up in handoff. But you cannot find an active order.", "key_points": [ "Stop on that medication until you can verify the order, dose, route, time, and last administration.", "Don’t sign for a dose you didn’t give or witness. Don’t chart in someone else’s MAR space.", "Assess the patient first: vitals, symptoms, sedation, pain, blood glucose, BP, allergies, or whatever fits the medication.", "Notify the charge nurse, provider, and pharmacy with facts: what was found, what is missing, and how the patient looks right now.", "Document what you know, how you know it, what you did, who you notified, and what orders or instructions you got." ], "one_thing": "Chart facts, not guesses: what you found, how you found it, how the patient looked, who you notified, and what happened next.", "what_goes_wrong": "The usual trap is trying to tidy up the MAR after the fact. You see that a medication was pulled from the ADC. Or someone says another nurse gave it. Then you chart it as given, not given, or late, even though you don’t actually know what happened.\n\nThat makes a bad record. The MAR has a simple job: show who gave what, by what route, at what time, and under what order. If the medication is not on the MAR, or there is no active order, don’t force it into a MAR box. Write a clear note. Keep facts separate from guesses.\n\nThe next nurse needs the practical answer: did the patient maybe get exposed to this med, is another dose safe, and who already knows about it.", "rewrites": [ { "situation": "", "before": "Norco pulled but not charted. Day shift must have given.", "after": "0718 During handoff review, eMAR showed no hydrocodone/APAP administration since 1900 yesterday. ADC dispense report showed hydrocodone/APAP 5/325 mg x1 removed at 0639 by RN [NAME]. I did not administer this dose and did not witness administration. Patient assessed: pain 4/10, RR 16, SpO2 96% RA, awake and oriented, no sedation noted. Charge RN [NAME], pharmacist [NAME], and provider [NAME] notified. No additional opioid administered pending clarification." }, { "situation": "", "before": "Patient took own meds. MD aware.", "after": "1030 Patient found with personal medication bottle labeled lisinopril 20 mg at bedside. Patient reported taking 1 tablet at approximately 1000. No active inpatient order for lisinopril located in eMAR at time of review. BP 118/72, HR 76, denies dizziness. Medication secured per facility process. Charge RN [NAME], pharmacist [NAME], and provider [NAME] notified at 1038. New order received to hold further antihypertensives today and monitor BP q4h." }, { "situation": "", "before": "Signed 0900 meds late for [NAME].", "after": "1505 eMAR showed metoprolol tartrate 25 mg due at 0900 with no administration or not-given documentation. I did not administer or witness the 0900 dose. Current BP 104/60, HR 58. Provider [NAME] notified at 1510 for direction regarding missed/late dose. Order received to hold missed 0900 dose and resume next scheduled dose if HR above [PARAMETER]." }, { "situation": "", "before": "Medication not on MAR. Pharmacy problem.", "after": "0842 Ceftriaxone 1 g IVPB noted in patient bin; medication label dated today 0805. No active ceftriaxone order and no ceftriaxone MAR row found in eMAR at time of review. Medication not administered by this RN. Pharmacist [NAME] notified at 0845 and stated order verification pending review. Provider [NAME] notified at 0850. Awaiting active order before administration." }, { "situation": "", "before": "I think patient got extra insulin. Will watch.", "after": "1216 Lunch tray arrived. eMAR showed insulin lispro 6 units scheduled with meal. ADC transaction history showed insulin lispro removed at 1152 by RN [NAME], but no MAR administration documented. I did not administer or witness insulin administration. Blood glucose at 1218 was 142 mg/dL. Patient alert, skin warm/dry, denies shakiness or sweating. Charge RN [NAME] and provider [NAME] notified. Per provider order, hold current lispro dose and recheck blood glucose at 1300." }, { "situation": "", "before": "Med error, no harm.", "after": "1735 Medication/order discrepancy identified: patient may have received gabapentin 300 mg at approximately 1700 based on medication cup found empty at bedside and patient report. No active gabapentin order located in eMAR at time of review. Patient awake, oriented, RR 18, gait not assessed, denies dizziness. Charge RN [NAME], pharmacist [NAME], and provider [NAME] notified. Fall precautions reviewed with patient. Monitoring continued per provider instruction." } ], "words_to_avoid": [ { "wording": "probably given", "why": "Turns a guess into a chart fact", "instead": "unable to verify administration" }, { "wording": "must have been given by days", "why": "Assigns an action you did not witness", "instead": "eMAR shows no administration documented; ADC shows removal by [NAME]" }, { "wording": "med error", "why": "A conclusion before review is complete", "instead": "medication/order documentation discrepancy identified" }, { "wording": "MD aware", "why": "Too vague to help the next clinician", "instead": "Dr. [NAME] notified at [TIME] of [FACTS]; order received: [ORDER]" }, { "wording": "no harm", "why": "Too broad and too early", "instead": "no symptoms observed or reported at [TIME]" }, { "wording": "covered for nurse", "why": "Suggests signing for someone else", "instead": "I did not administer or witness the dose" }, { "wording": "charted late for previous shift", "why": "Makes timing and responsibility unclear", "instead": "actual administration time unknown; prior dose not documented" }, { "wording": "pharmacy issue", "why": "Blames a department without facts", "instead": "no active MAR entry/order located at time of review; pharmacy notified" } ], "cases": [ { "case": "Davis v. Louisiana State Board of Practical Nurse Examiners", "url": "https://www.courtlistener.com/opinion/1557145/davis-v-louisiana-state-board-of-practical-nurse-examiners/", "court": "Louisiana Court of Appeal", "year": "2009", "quote": "", "what_it_shows": "The allegations included medication without a physician order and MAR/controlled-substance documentation problems. The court affirmed the Board’s license revocation and related sanctions. One line from the decision: “Ms. Davis administered 3 tablets of Tylenol P.M. to a resident without a physician's order.”" }, { "case": "Ethridge v. Arizona State Board of Nursing", "url": "https://www.courtlistener.com/opinion/1262460/ethridge-v-arizona-state-board-of-nursing/", "court": "Court of Appeals of Arizona", "year": "1989", "quote": "", "what_it_shows": "The court reviewed nursing-board discipline involving medication-order and charting issues, then affirmed in part and vacated in part. One line from the decision: “Eaves administered Percocet-Demi to a patient without first obtaining physician orders”" } ], "guidance": [ { "says": "If the eMAR, barcode scanner, medication label, or ADC information does not match, stop. Check it before you give the dose or document it.", "sources": [ { "name": "NCBI Bookshelf", "url": "https://www.ncbi.nlm.nih.gov/books/NBK593215/" }, { "name": "Nursing Skills 2e", "url": "https://wtcs.pressbooks.pub/nursingskills/chapter/15-2-basic-concepts-of-administering-medications/" } ] }, { "says": "Medication documentation should be done on time and should match what actually happened, including the patient’s response when that response matters clinically.", "sources": [ { "name": "OpenStax", "url": "https://openstax.org/books/clinical-nursing-skills/pages/11-3-documentation-of-medication-administration" }, { "name": "LibreTexts", "url": "https://med.libretexts.org/Bookshelves/Nursing/Clinical_Nursing_Skills_(OpenStax" } ] }, { "says": "When a dose is refused or not given, chart the reason and the follow-up. Don’t leave the record sitting there with no explanation.", "sources": [ { "name": "Montana DPHHS", "url": "https://dphhs.mt.gov/assets/BHDD/DDP/MedicalDirector/TheMARhowtofilloutanduse.pdf" }, { "name": "NursingCenter", "url": "https://www.nursingcenter.com/upload/journals/documents/200303nsoce1risks.htm" } ] } ], "ready_to_copy": "[DATE] [TIME] Medication/order discrepancy identified during [HANDOFF/MED PASS/CHART REVIEW]. [MEDICATION] [DOSE] [ROUTE] was [FOUND AT BEDSIDE/REPORTED BY PATIENT/SHOWN AS REMOVED FROM ADC/OTHER], but no active order or MAR entry was located in [EHR/MAR] at the time of review. I did not administer this medication and did not witness administration. Last documented administration in MAR: [DATE/TIME OR NONE FOUND]. Patient assessment: [VITALS], [PAIN/SEDATION/MENTAL STATUS/OTHER RELEVANT FINDINGS]. Charge RN [NAME] notified at [TIME]. Pharmacist [NAME] notified at [TIME]. Provider [NAME] notified at [TIME] with above information. Orders received: [ORDERS OR NO NEW ORDERS]. Actions taken: [MED HELD/DOSE NOT GIVEN/PERSONAL MED SECURED/MONITORING/OTHER]. Patient response at [TIME]: [RESPONSE].", "samples_are_written": true }, { "slug": "patient-denies-med", "title": "When the Patient Says the Charted Pain Dose Was Not Given", "search_title": "", "question": "How do I chart a medication discrepancy when the MAR shows a controlled pain medication was given but the patient says they did not receive it or remains in severe pain?", "asked_as": "site:allnurses.com patient says pain med not given MAR says administered what to chart", "cluster": "trouble", "url": "https://shiftiswild.com/notes/patient-denies-med/", "markdown_url": "https://shiftiswild.com/notes/patient-denies-med.md", "summary": "The MAR says a controlled pain med was given. The patient says they did not get it, or their pain is still severe. Don’t try to solve the whole thing in one note. That is not the job.\nYour job is to document what you know, assess the patient, avoid a duplicate dose, and get the right people involved.", "key_points": [ "Assess the patient now: pain score, location, sedation, respiratory status, vitals, and visible distress.", "Chart the patient’s statement as a statement. Not as proof that the MAR is wrong.", "Compare the eMAR, dispensing record, waste record, and controlled-substance count per facility process.", "Notify the charge nurse and provider promptly, especially before giving another opioid dose.", "Do not accuse, erase, overwrite, or document blame. Use the facility occurrence report outside the chart if required." ], "one_thing": "Chart what you know right now, not who you think is at fault.", "what_goes_wrong": "The usual mistake is writing the conclusion before you have the facts.\n\nExample: Med charted but not given or possible diversion by prior nurse.\n\nThat may feel direct. It is also a problem. You just skipped several possibilities: the dose may have been given but not worked, given late, documented under the wrong time, wasted incorrectly, scanned incorrectly, or entered on the wrong patient.\n\nWith controlled meds, the chart, dispensing cabinet, waste record, and count all need to line up. If they do not, your note should show the discrepancy and what you did next. Not your guess about why it happened.\n\nAnother mistake: giving another full opioid dose just because the patient says they did not get the first one. The patient may be telling the truth. The MAR still shows an administered dose. Until the discrepancy is clarified, or the provider gives you a safe plan, treat it as two problems at once: pain control and medication safety.", "rewrites": [ { "situation": "", "before": "Patient claims 2100 Dilaudid was not given. Prior nurse must have charted it wrong.", "after": "2135 Patient awake in bed, guarding abdomen, reports pain 9/10. Patient states: I did not receive the 2100 hydromorphone dose. eMAR reviewed and shows hydromorphone 0.5 mg IV documented at 2102 by [NAME]. This RN did not observe that administration. RR 18, SpO2 96 percent on room air, sedation score 1. Charge RN [NAME] notified at 2140. Provider [NAME] notified at 2145 for pain plan and medication discrepancy review." }, { "situation": "", "before": "Med error. Oxycodone charted but patient did not get it.", "after": "1840 On assuming care, patient reports oxycodone dose due earlier was not received. eMAR shows oxycodone 5 mg PO documented as administered at 1748 by [NAME]. Patient reports pain 8/10 in right hip. BP 132/78, HR 92, RR 16, alert and oriented. Charge RN notified. Controlled-substance reconciliation requested per unit process. Awaiting provider direction before additional opioid dose." }, { "situation": "", "before": "Patient still screaming after morphine. Wants more narcotics.", "after": "1515 Pain reassessment completed 45 minutes after eMAR-documented morphine 2 mg IV at 1430. Patient reports pain remains 10/10 in left lower quadrant. Patient crying, knees flexed, abdomen tender to light palpation. RR 20, SpO2 97 percent, sedation score 1. Provider notified of uncontrolled pain after ordered PRN dose. No additional opioid given without new order." }, { "situation": "", "before": "Gave another dose because patient said she did not get the first one.", "after": "1005 Patient states prior hydromorphone dose was not received. eMAR shows hydromorphone 0.4 mg IV documented at 0930. Due to existing administered entry, no repeat opioid dose given at this time. Charge RN and provider notified. Patient repositioned, heat pack applied per order, call light in reach. Pain to be reassessed after provider plan." }, { "situation": "", "before": "Possible diversion by night nurse.", "after": "0710 Controlled medication discrepancy identified during review of hydromorphone 1 mg/mL. eMAR shows dose administered at 0645. Dispensing record and remaining count do not match expected count. Charge RN [NAME] and pharmacy [NAME] notified. Reconciliation in progress per facility policy. Patient assessed for pain and sedation." } ], "words_to_avoid": [ { "wording": "Lying", "why": "You’re accusing the patient instead of charting clinical facts.", "instead": "Patient states dose was not received" }, { "wording": "Drug-seeking", "why": "You’re labeling the patient instead of assessing pain and safety.", "instead": "Patient reports pain [NUMBER]/10 and requests pain medication" }, { "wording": "Diversion", "why": "That is an investigation conclusion. Don’t put it in a bedside note unless it has been formally determined.", "instead": "Controlled-substance discrepancy identified" }, { "wording": "Nurse charted falsely", "why": "You’re accusing another staff member without verification.", "instead": "eMAR shows dose documented by [NAME]; this RN did not observe administration" }, { "wording": "Med error", "why": "It may be true later. Often, you do not know that at the time of the note.", "instead": "Medication discrepancy noted; review initiated" }, { "wording": "No relief, probably faking", "why": "Unsupported. Dismissive. Not useful.", "instead": "Patient reports pain remains [NUMBER]/10; observed [OBJECTIVE FINDINGS]" }, { "wording": "Incident report completed", "why": "Facility reports usually stay outside the medical record.", "instead": "Charge RN notified; follow-up per facility policy" } ], "cases": [ { "case": "Henning v. Avera McKennan", "url": "https://www.courtlistener.com/opinion/9507894/henning-v-avera-mckennan/", "court": "South Dakota Supreme Court", "year": "2020", "quote": "", "what_it_shows": "The hospital tracked controlled-substance removals, administration documentation, waste, and unaccounted medication. The nurse was terminated after documentation errors and inability to account for controlled substances; the South Dakota Supreme Court affirmed summary judgment for the hospital." }, { "case": "KELLY-KOFFI v. Wesley Medical Center", "url": "https://www.courtlistener.com/opinion/2578116/kelly-koffi-v-wesley-medical-center/", "court": "District Court, D. Kansas", "year": "2003", "quote": "", "what_it_shows": "The record involved narcotic documentation discrepancies, chart review, and termination. The court granted summary judgment for the employer." }, { "case": "Gabriel v. County of Herkimer", "url": "https://www.courtlistener.com/opinion/8718656/gabriel-v-county-of-herkimer/", "court": "District Court, N.D. New York", "year": "2012", "quote": "", "what_it_shows": "The court record included complaints that medications were wrong, a MAR, a narcotics list, and security-log inconsistencies. This is the type of record where clear medication documentation and follow-up matter." } ], "guidance": [ { "says": "Medication administration belongs on the MAR or eMAR. If there is a medication-documentation problem, fix it through the medication documentation workflow. Don’t hide it in a narrative note.", "sources": [ { "name": "health.maryland.gov", "url": "https://health.maryland.gov/springgrove/Policy/Nursing/Medication%20Administration.pdf" }, { "name": "openstax.org", "url": "https://openstax.org/books/clinical-nursing-skills/pages/11-3-documentation-of-medication-administration" } ] }, { "says": "If a medication was not given, the MAR should show that it was not given using the system or paper process your facility requires.", "sources": [ { "name": "cstcernerhelp.healthcarebc.ca", "url": "https://cstcernerhelp.healthcarebc.ca/Patient_Chart/MAR/Document_Medication_Not_Given_and_Medication_Not_Done_(PHC_LTC" }, { "name": "med.libretexts.org", "url": "https://med.libretexts.org/Bookshelves/Nursing/Clinical_Nursing_Skills_(OpenStax" } ] }, { "says": "For PRN pain medication, document the pain rating and reassess after administration so the chart shows the patient’s response.", "sources": [ { "name": "health.maryland.gov", "url": "https://health.maryland.gov/springgrove/Policy/Nursing/Medication%20Administration.pdf" }, { "name": "wtcs.pressbooks.pub", "url": "https://wtcs.pressbooks.pub/nursingskills/chapter/15-3-assessments-related-to-medication-administration/" } ] } ], "ready_to_copy": "[DATE] [TIME] Patient assessed after report of uncontrolled pain and concern about medication administration. Patient alert and oriented to [LEVEL]. Patient states: [PATIENT WORDS ABOUT NOT RECEIVING DOSE]. Pain [NUMBER]/10 at [LOCATION], described as [QUALITY]. Objective findings: [GUARDING/GRIMACING/RESTLESSNESS/OTHER]. Vital signs: BP [BP], HR [HR], RR [RR], SpO2 [SPO2], sedation score [SCORE].\n\neMAR reviewed. eMAR shows [MEDICATION] [DOSE] [ROUTE] documented as administered at [TIME] by [NAME]. This RN did not observe that administration. No additional opioid dose given at this time pending clarification and provider direction.\n\nCharge RN [NAME] notified at [TIME]. Provider [NAME] notified at [TIME] of patient report, current pain score, vital signs, sedation status, and eMAR entry. Controlled-substance reconciliation initiated per facility policy by [NAME/ROLE]. Patient updated on plan. Pain and sedation to be reassessed by [TIME].", "samples_are_written": true }, { "slug": "tampered-med-package", "title": "When a Syringe or Vial Looks Wrong Before You Give It", "search_title": "", "question": "What should I document if medication packaging, a syringe, vial, seal, or bag looks wrong before administration?", "asked_as": "nurse found tampered syringe vial seal what to document notify pharmacy", "cluster": "trouble", "url": "https://shiftiswild.com/notes/tampered-med-package/", "markdown_url": "https://shiftiswild.com/notes/tampered-med-package.md", "summary": "You catch something off before you give a med: syringe, vial, seal, label, cap, bag, wrapper. Stop. Don’t use it. Don’t guess. Chart what you actually saw and what you did next.", "key_points": [ "Stop before administration. If the packaging looks opened, damaged, mislabeled, cloudy, leaking, punctured, cored, or just not right, don’t use it.", "Chart what you can see: the product, the problem, where it came from, whether it was opened, and whether any dose reached the patient.", "If the dose was not given, chart it as not given or held. Don’t chart it as administered “for now.”", "Tell the charge nurse, pharmacy, and provider if the patient care situation needs it. If it’s controlled, follow your facility’s controlled-substance process.", "Preserve, return, waste, or discard the item per policy. Chart where it went and who witnessed it if that is required." ], "one_thing": "Chart what you saw, not what you suspect.", "what_goes_wrong": "The usual mistake is writing the conclusion instead of the facts.\n\n“Vial tampered with” may feel clear in the moment. It is not enough. What made you think that? Was the seal lifted? Was the cap loose? Was the label different from the MAR? Was there a particle floating in the vial? Was the bag already spiked? Was the wrapper torn before you opened it?\n\nThe second mistake is cleaning up the problem so fast that the chart no longer explains the gap. You toss the item, pull another dose, and chart only “med given.” Later, that can look like a missing dose, a late dose, a waste issue, or a controlled-substance discrepancy with no story behind it.\n\nUse the same pattern every time:\n\n1. I checked it before giving it.\n2. I saw this specific problem.\n3. I did not administer it.\n4. I notified these people.\n5. This is where the item went.\n6. This is how the patient’s medication need was handled.", "rewrites": [ { "situation": "", "before": "“Dilaudid vial looked tampered with. Pharmacy aware.”", "after": "“0805 Hydromorphone 1 mg/mL vial removed from ADC for ordered 0.5 mg IV dose. Before opening, clear top seal noted lifted on left edge with adhesive exposed. Vial cap remained in place. Medication not administered. Charge RN J. Lee notified at 0808; pharmacy notified at 0810. Vial kept in original packaging and given to pharmacy at 0815 per policy. Replacement vial obtained; 0.5 mg IV administered at 0822. Pain 8/10 before dose, 5/10 at 0850.”" }, { "situation": "", "before": "“Scanned fine but label seemed wrong.”", "after": "“1402 Cefazolin IVPB bag delivered for patient with active order for ceftriaxone 1 g IV q24h. Bag label medication name did not match MAR order. Bag not spiked and medication not administered. Pharmacy notified at 1405. Dose held pending replacement from pharmacy. Provider notified of delay at 1410.”" }, { "situation": "", "before": "“Vial had rubber in it, wasted.”", "after": "“1120 Heparin vial inspected after cap removal and before administration. Black rubber-appearing particle approximately 1 mm noted floating in solution. No dose from this vial administered. Vial labeled ‘do not use’ and placed in pharmacy return bag per policy. Pharmacy notified. New vial obtained for ordered dose.”" }, { "situation": "", "before": "“Flush was open so I used another one.”", "after": "“0745 Prepackaged 10 mL NS flush found in medication drawer with outer wrapper torn at plunger end before use. Syringe not used for patient care. Syringe discarded per unit policy. New sealed flush used.”" }, { "situation": "", "before": "“Narcotic discrepancy fixed with witness.”", "after": "“2105 Oxycodone 5 mg unit-dose package removed from ADC. Blister backing noted partially peeled open before administration; tablet visible. Dose not administered. Charge RN A. Patel witnessed package condition. ADC discrepancy process initiated per policy. Pharmacy notified at 2110. Package secured per controlled-substance policy. Replacement dose obtained and administered at 2120. Pain 7/10 before dose, 4/10 at 2200.”" } ], "words_to_avoid": [ { "wording": "“Tampered with”", "why": "It is a conclusion unless you know who did what.", "instead": "“Seal lifted,” “cap loose,” “wrapper torn,” “bag punctured,” “label mismatch noted.”" }, { "wording": "“Stolen”", "why": "Accuses someone without documenting the observation.", "instead": "“Medication not located in expected pocket,” “package found open,” “ADC count discrepancy noted.”" }, { "wording": "“Diverted”", "why": "Usually not your bedside finding; it is an investigation conclusion.", "instead": "“Controlled-substance discrepancy reported per policy.”" }, { "wording": "“Looked sketchy/weird”", "why": "Too vague to help anyone reconstruct the event.", "instead": "Describe size, color, location, label, seal, cap, wrapper, fluid, particles." }, { "wording": "“Probably saline”", "why": "You usually cannot identify contents by appearance.", "instead": "“Contents clear; medication identity/potency not verified.”" }, { "wording": "“Pharmacy messed up”", "why": "Assigns blame instead of documenting the mismatch.", "instead": "“Pharmacy label reads [X]; MAR order reads [Y].”" }, { "wording": "“Wasted it”", "why": "Incomplete for controlled substances and unclear for noncontrolled meds.", "instead": "“Not administered; discarded in [LOCATION] per policy” or “wasted with [WITNESS] in ADC.”" }, { "wording": "“Sterile”", "why": "You may not be able to prove sterility.", "instead": "“Packaging intact” or “sterility questionable due to torn wrapper.”" } ], "cases": [ { "case": "**Leonard Boyd v. Central Iowa Hospital Corp., d/b/a Iowa Methodist Medical Center**", "url": "https://www.courtlistener.com/opinion/10612771/leonard-boyd-v-central-iowa-hospital-corp-dba-iowa-methodist-medical/", "court": "Court of Appeals of Iowa", "year": "2025", "quote": "", "what_it_shows": "Link: This case involved allegations that a pharmacy technician diluted narcotic vials and used computer transactions to conceal it. The opinion notes: “Opening the vial would sometimes break the tamper tape on top.” The hospital’s medication records and transaction records became part of the later review." }, { "case": "**Ex parte Air Evac EMS, Inc.**", "url": "https://www.courtlistener.com/opinion/10360808/ex-parte-air-evac-ems-inc-petition-for-writ-of-mandamus-in-re-ex-parte/", "court": "Supreme Court of Alabama", "year": "2025", "quote": "", "what_it_shows": "Link: The amended complaint alleged ketamine had been removed and replaced with saline before transport. One allegation was failure to “properly document in the medical records that [Earnest] was administered a dosage of ketamine that was believed to have been tampered with or otherwise compromised”. The court dealt with limitations and relation-back issues. The bedside point is simple: if you think a medication may be compromised, the chart needs the concrete facts." }, { "case": "**State v. Vaughn**", "url": "https://www.courtlistener.com/opinion/10619964/state-v-vaughn/", "court": "Ohio Court of Appeals", "year": "2025", "quote": "", "what_it_shows": "Link: This was not a medication-administration case, but it shows how container condition, collection steps, and transfer details can matter later. The court wrote: “Here, we find the State substantially complied with the regulation because appellant's urine was collected in a clean, single-use, cardboard bedpan and transferred into the appropriate plastic container from the OVI test kit immediately after.”" } ], "guidance": [ { "says": "If sterility is compromised or even questionable, don’t use that medication container. Take it out of use and get a replacement per policy.", "sources": [ { "name": "NCBI Bookshelf", "url": "https://www.ncbi.nlm.nih.gov/books/NBK596739/" }, { "name": "CDC", "url": "https://www.cdc.gov/injection-safety/hcp/clinical-safety/index.html" } ] }, { "says": "Your medication check includes the actual label and packaging. Not memory. Not habit. If the label is unclear or does not match the order, stop there.", "sources": [ { "name": "NCBI Bookshelf", "url": "https://www.ncbi.nlm.nih.gov/books/NBK560654/" }, { "name": "FDA", "url": "https://www.fda.gov/media/158522/download" } ] }, { "says": "Don’t chart a medication as administered before it is actually given. If you hold it because the package looks wrong, chart held or not administered and say why.", "sources": [ { "name": "LibreTexts", "url": "https://med.libretexts.org/Bookshelves/Nursing/Clinical_Nursing_Skills_(OpenStax" }, { "name": "OpenStax", "url": "https://openstax.org/books/clinical-nursing-skills/pages/11-3-documentation-of-medication-administration" } ] } ], "ready_to_copy": "[DATE] [TIME] Prior to administration of [MEDICATION] [DOSE] [ROUTE] for [PATIENT INITIALS/MRN], [VIAL/SYRINGE/BAG/UNIT-DOSE PACKAGE] was inspected. Finding: [OBJECTIVE DESCRIPTION OF WHAT LOOKED WRONG]. Medication from this item was not administered. Patient status at time of hold: [RELEVANT ASSESSMENT, PAIN SCORE, VITALS, OR REASON MED WAS ORDERED]. Charge RN [NAME] notified at [TIME]. Pharmacy notified at [TIME]. Item was [SECURED/RETURNED/DISCARDED] per facility policy: [WHERE IT WENT AND TO WHOM]. Replacement medication [WAS/WAS NOT] obtained. [MEDICATION] [DOSE] [ROUTE] administered from replacement supply at [TIME], if applicable. Patient response/follow-up: [RESPONSE OR PLAN].", "samples_are_written": true }, { "slug": "harm-to-others", "title": "When a patient says they might hurt someone", "search_title": "", "question": "What exactly should I document when a patient mentions thoughts, urges, threats, targets, or plans to hurt another person?", "asked_as": "nurse document homicidal ideation threat to harm others target plan notify provider", "cluster": "trouble", "url": "https://shiftiswild.com/notes/harm-to-others/", "markdown_url": "https://shiftiswild.com/notes/harm-to-others.md", "summary": "Patients say this in different ways: during intake, while psychotic, while angry, half-casual, or as a straight threat. Your note needs to show what they said, what you assessed, who might be at risk, and what you did next.", "key_points": [ "Write the patient’s words as close as you can. Don’t clean them up.", "Chart target, plan, intent, means or access, timeframe, and triggers.", "If voices, paranoia, intoxication, dementia, delirium, or agitation are part of it, chart what you saw and what the patient reported.", "Write who you notified, when, and what safety steps started.", "Don’t write only HI, threatening, or contracted for safety and stop there." ], "one_thing": "Don’t chart only the label. Chart the words, target, plan, means, timing, and what you did next.", "what_goes_wrong": "The usual mistake: you chart a label, not the risk picture.\n\nBad note: Patient is HI. MD aware.\n\nThat tells the next nurse almost nothing. Is the patient having intrusive thoughts they don’t want? Are they angry at some unnamed group? Did they name a spouse, coworker, nurse, roommate, judge, neighbor, or child? Do they have a weapon? Are they leaving in 20 minutes? Are they hearing voices? Did anyone notify the provider, charge nurse, security, or receiving unit?\n\nHI is not the problem. By itself, HI is just your conclusion. The chart needs the facts that got you there, and what happened after.", "rewrites": [ { "situation": "", "before": "Patient is HI. MD aware.", "after": "1910: Pt stated: I am going to kill my brother when I get out. Pt identified brother J.R. as target, states brother lives with pt. Pt reports plan to stab him with kitchen knife at home tonight. Pt reports access to knives at home, denies firearm access. Pt pacing in room, voice loud, fists clenched. Charge RN notified 1912, psychiatry resident paged 1913, security to unit 1915. Pt moved to room closer to nurses station per unit safety process." }, { "situation": "", "before": "Pt threatened staff.", "after": "2240: During medication pass, pt pointed at this RN and stated: I will break your neck if you come in here again. Pt standing 3 feet from doorway, blocking entrance. No physical contact. MHT A.B. present. RN stepped back, maintained open exit, charge RN notified. Security called to unit. Medication not administered at that time due to safety concern; provider notified 2248." }, { "situation": "", "before": "Denies HI. Contracted for safety.", "after": "0830: Pt denies current thoughts of harming others. Earlier statement from night shift reviewed with pt. Pt states: I said I wanted to punch my roommate because I was angry. Pt denies plan, denies intent, denies weapon access on unit, denies target other than roommate. Pt agrees to notify staff before approaching roommate. Room assignment changed; pt remains on q15 min safety checks per order. Provider updated 0840." }, { "situation": "", "before": "Pt psychotic and dangerous.", "after": "1435: Pt reports hearing a male voice telling him to hit coworker M.S. with a wrench. Pt states coworker is real and works with him at ABC warehouse. Pt states urge is 8/10 and says he has a wrench in his truck at home. Pt denies firearm access. Pt appears internally preoccupied, pauses before answering, looks toward corner of room. NP notified 1440; discharge held pending reassessment." }, { "situation": "", "before": "Family says patient threatened neighbor.", "after": "1015: Pt’s sister called unit and reported pt told her by phone today that he was going to shoot the upstairs neighbor. Pt present during call follow-up and states he is angry with neighbor but denies intent to harm him. Pt reports owning one handgun kept at home in bedroom closet. Provider and charge RN notified 1022. Safety plan and disposition reviewed by provider." }, { "situation": "", "before": "Pt became aggressive.", "after": "1718: Pt struck wall with right fist twice after being told discharge paperwork was not ready. Pt stated: I will come back here and hurt whoever is delaying me. No specific person named when asked. Pt denied weapon on person. Right hand skin intact, mild redness over knuckles; ice offered. Security present 1721. Provider notified 1725." } ], "words_to_avoid": [ { "wording": "HI", "why": "Too vague by itself", "instead": "Thoughts of harming others present or denied, plus target, plan, intent, means, timeframe" }, { "wording": "Threatening", "why": "A conclusion without the words or behavior", "instead": "Pt stated: [exact words]. Pt stood [distance], pointed at [person], blocked [exit/door]" }, { "wording": "Dangerous", "why": "Labels the patient but does not describe risk", "instead": "Specific behavior, statement, access to weapon, recent violence, current impulse control" }, { "wording": "Psychotic", "why": "Too broad if used alone", "instead": "Pt reports voice saying [content]; pt states belief that [person] is trying to harm him" }, { "wording": "No plan", "why": "Weak if you did not ask about means, access, or timing", "instead": "Denies plan to harm [target]; denies weapon access; denies intent; denies timeframe" }, { "wording": "Contracted for safety", "why": "Does not show what was assessed or what changed", "instead": "Pt agreed to notify staff before approaching [person]; safety checks/room change/provider notification documented" }, { "wording": "Manipulative", "why": "Judgmental and not useful", "instead": "Pt requested [item/action]; when request denied, pt stated [words] and did [observable behavior]" }, { "wording": "Calm now", "why": "May erase the earlier risk", "instead": "At [time], pt sitting on bed, voice normal volume; continues to deny/endorse [specific risk items]" } ], "cases": [ { "case": "Caples v. Sinai Hospital of Baltimore, Inc.", "url": "https://www.courtlistener.com/opinion/10851854/caples-v-sinai-hospital-of-baltimore-inc/", "court": "Court of Special Appeals of Maryland", "year": "2026", "quote": "Where a patient expresses violent ideation toward those in their vicinity, at a minimum, the provider or administrator must warn those to whom the patient is being discharged.", "what_it_shows": "" }, { "case": "State ex rel. Jones v. Hoying", "url": "https://www.courtlistener.com/opinion/10332782/state-ex-rel-jones-v-hoying/", "court": "Ohio Court of Appeals", "year": "2025", "quote": "On [April 16, 2024], Mr. Jones stated that he wished to kill his parole officer. When asked if he had access to weapons, he stated “I have people on the street.”", "what_it_shows": "" } ], "guidance": [ { "says": "When violence is a concern, ask directly about harming others and about weapons or other means.", "sources": [ { "name": "NCBI Bookshelf", "url": "https://www.ncbi.nlm.nih.gov/books/NBK590028/" }, { "name": "NurseChartingPro", "url": "https://nursechartingpro.com/guides/safety-assessment-charting" } ] }, { "says": "Chart the patient’s actual words, the target or possible target, plan, intent, access to means, timing, and what you did after.", "sources": [ { "name": "NurseChartingPro", "url": "https://nursechartingpro.com/guides/safety-assessment-charting" }, { "name": "Neurolaunch", "url": "https://neurolaunch.com/how-to-document-inappropriate-patient-behavior/" } ] }, { "says": "Follow your facility process for violent behavior. That may mean charge nurse, supervisor, security, provider, or internal reporting when required.", "sources": [ { "name": "NursingCenter", "url": "https://www.nursingcenter.com/journalarticle?Article_ID=952507&Journal_ID=54016&Issue_ID=952351" }, { "name": "Neurolaunch", "url": "https://neurolaunch.com/how-to-document-inappropriate-patient-behavior/" } ] }, { "says": "Include safety interventions and how the patient responded. Don’t stop at the risk statement.", "sources": [ { "name": "NurseChartingPro", "url": "https://nursechartingpro.com/guides/safety-assessment-charting" }, { "name": "ICANotes", "url": "https://www.icanotes.com/2018/02/16/10-things-every-psychiatric-nurses-progress-note/" } ] } ], "ready_to_copy": "[DATE] [TIME]: Patient assessed after statement about harming another person. Patient stated: [EXACT WORDS USED BY PATIENT]. Patient identified target as [NAME/RELATIONSHIP/GENERAL GROUP/NONE IDENTIFIED]. Patient reports plan: [PLAN OR DENIES PLAN]. Patient reports intent: [INTENT LEVEL OR DENIES INTENT]. Patient reports timeframe: [TIMEFRAME OR DENIES TIMEFRAME]. Patient reports access to means/weapons: [MEANS/WEAPON ACCESS OR DENIES ACCESS]. Patient reports precipitating factor as [TRIGGER/EVENT OR UNKNOWN].\n\nMental status/behavior observed: [APPEARANCE, SPEECH, AFFECT, AGITATION, INTOXICATION, CONFUSION, PARANOIA, HALLUCINATIONS, OR OTHER OBSERVED FINDINGS]. Patient [DENIES/ENDORSES] auditory or visual hallucinations. If present, patient reports content: [CONTENT]. Patient [DENIES/ENDORSES] suicidal ideation.\n\nSafety actions taken: [PATIENT LOCATION/OBSERVATION LEVEL/ROOM CHANGE/SEPARATION FROM TARGET/ITEMS REMOVED/SECURITY PRESENT/OTHER]. Notifications: [PROVIDER NAME/TITLE] notified at [TIME]; [CHARGE RN/SUPERVISOR] notified at [TIME]; [SECURITY/OTHER TEAM] notified at [TIME]. New orders or plan: [ORDERS/NO NEW ORDERS/PENDING EVALUATION]. Patient response after intervention: [RESPONSE].", "samples_are_written": true }, { "slug": "suicide-observation", "title": "Charting Suicide Precautions So the Record Shows Actual Observation", "search_title": "", "question": "What should I chart during 1:1 or q15 suicide precautions so the record shows the patient’s behavior, location, environment checks, missed checks, and escalation?", "asked_as": "nurse forum charting q15 suicide precautions sitter documentation patient sleeping", "cluster": "trouble", "url": "https://shiftiswild.com/notes/suicide-observation/", "markdown_url": "https://shiftiswild.com/notes/suicide-observation.md", "summary": "A q15 check or 1:1 note has one job: show that somebody actually laid eyes on the patient and checked the safety situation right then. Chart where the patient was, what they were doing, what the room looked like, what changed, and what staff did when a check was late, missed, or not enough.", "key_points": [ "Chart what you saw, not the order. Time, location, activity, behavior, visibility, and environment.", "For 1:1, do not let the note stop at sitter present. If your facility requires q15 entries, chart the patient’s actual status at that interval.", "If a check is late or missed, say it was late or missed. Do not backfill it like it happened on time.", "Escalate and document when behavior changes, the patient makes new suicidal statements, an environmental risk shows up, or staff cannot keep the ordered observation level.", "Skip blanket notes like q15 done, patient safe, or sitter at bedside. They do not show actual observation." ], "one_thing": "Chart what you actually saw. Not what was supposed to happen.", "what_goes_wrong": "The usual mistake is charting the precaution level instead of the patient.\n\nFor example, q15 checks maintained tells the reader the checks were ordered or intended. It does not show that the patient was seen at 0715, in the bathroom doorway, with bedding checked, trash removed, hands visible, breathing even, and no ligature item in reach.\n\nThat gap matters. Suicide precautions are visual and environmental. The next person reading the chart needs to know:\n\n- Was the patient actually seen?\n- Where was the patient?\n- Was the patient in bed, bathroom, hallway, shower, dayroom, or behind a closed door?\n- What behavior did staff observe?\n- Were cords, linens, trash, trays, sharps, bags, and belongings checked?\n- Was the sitter relieved, distracted, blocked from view, or unable to see the patient?\n- If a check was missed or late, who was notified and what changed?\n\nA good note does not need to be long. It needs to be specific.", "rewrites": [ { "situation": "", "before": "0715 q15 done. Pt safe.", "after": "0715 Pt visually observed in room 412, sitting on bed facing doorway. Awake, tearful, rubbing hands together. Hands and neck visible. No self-harm gestures observed. Trash can empty; meal tray removed; bathroom door open; no cords or loose items visible from doorway. q15 precautions continued." }, { "situation": "", "before": "0230 Pt sleeping.", "after": "0230 Pt observed in bed, left side, eyes closed. Chest rise visible; respirations even and unlabored. Room light on per suicide precautions. Bedding on bed only; no extra linens observed. Bathroom door open. q15 precautions continued." }, { "situation": "", "before": "1:1 at bedside, no issues.", "after": "1430 Continuous 1:1 observation maintained by MHT Davis, seated inside doorway with unobstructed view of patient. Pt in recliner watching TV, hands visible, calm, responds to name. No self-harm gestures observed. Environment scan completed: tray removed, trash empty, belongings secured per precautions." }, { "situation": "", "before": "Pt in bathroom.", "after": "1015 Pt requested bathroom. Staff maintained observation per unit suicide precaution policy. Bathroom door remained ajar. Pt voided, washed hands, and returned to bed at 1019. No items retained by patient. Sink area, toilet area, and door checked after use; no safety concerns observed." }, { "situation": "", "before": "1500 check late due to busy unit.", "after": "1500 scheduled q15 visual check not completed at 1500. Pt next visually observed at 1506 in hallway with MHT Lee, walking slowly, calm, hands visible, no injury observed. Charge RN Patel notified at 1507. Provider Nguyen paged at 1510 to review observation level. q15 checks resumed; next check due 1515." }, { "situation": "", "before": "Cord removed.", "after": "1635 During room safety check, phone cord found within reach from bed. Pt in dayroom with MHT Smith at time of finding. Cord removed at 1636 and secured outside room. Room rechecked: no additional cords, sharps, bags, or extra linens observed. Charge RN notified at 1638." }, { "situation": "", "before": "MD aware.", "after": "1846 Provider Nguyen notified by phone: pt pacing in hallway, repeatedly looking toward exit, stated unable to stay safe tonight, and required redirection away from bathroom twice since 1830. Continuous 1:1 maintained. Order received at 1855 to increase from q15 to 1:1 and continue ligature-risk room precautions." }, { "situation": "", "before": "Pt denies SI.", "after": "2100 Pt awake in bed, calm, makes eye contact. Pt denies suicidal thoughts, plan, or intent at this time. No self-harm gestures observed. Remains on q15 suicide precautions per current order due to recent risk assessment. Room safety check completed; no hazards observed." } ], "words_to_avoid": [ { "wording": "safe", "why": "Conclusion, not observation", "instead": "No self-harm gestures observed; hands visible; room check completed" }, { "wording": "checked", "why": "Does not say what was seen", "instead": "Visually observed in room, sitting on bed, awake, hands visible" }, { "wording": "q15 done", "why": "Shows task completion, not patient status", "instead": "0715 Pt observed in dayroom, talking with staff, calm" }, { "wording": "asleep", "why": "Can sound like certainty without assessment", "instead": "Appears asleep; eyes closed; chest rise visible; respirations even" }, { "wording": "no issues", "why": "Too vague", "instead": "No ligature items observed; no self-harm gestures; denies SI at this time" }, { "wording": "sitter present", "why": "Does not show line of sight", "instead": "1:1 staff seated inside doorway with continuous unobstructed view" }, { "wording": "bathroom privileges", "why": "Does not show observation or environment", "instead": "Bathroom used with observation per policy; door ajar; area checked after use" }, { "wording": "MD aware", "why": "Does not show what was reported", "instead": "Provider notified of patient statement, behavior, current precautions, and actions taken" }, { "wording": "noncompliant", "why": "Labels the patient", "instead": "Refused to change into safety gown; reason stated; charge RN notified" }, { "wording": "missed because short staffed", "why": "Explains staffing but not patient status", "instead": "Check not completed at scheduled time; patient next observed at time; charge RN notified; precautions adjusted" } ], "cases": [ { "case": "D.P. v. Wrangell General Hospital", "url": "https://www.courtlistener.com/opinion/2590180/dp-v-wrangell-general-hospital/", "court": "Alaska Supreme Court", "year": "2000", "quote": "The nurses' notes show that each nurse regularly checked on D.P. at intervals ranging from a few minutes to two hours.", "what_it_shows": "The opinion describes a patient admitted under observation/suicide precautions who left the hospital. The court reversed a directed verdict and sent the case back for trial on whether supervision was reasonable." }, { "case": "Stewart v. Vivian", "url": "https://www.courtlistener.com/opinion/3201626/stewart-v-vivian/", "court": "Ohio Court of Appeals", "year": "2016", "quote": "During this conversation, Dr. Vivian ordered that Michelle be placed on \"15-minute checks,\" a level of observation that required a hospital staff member to visually check on Michelle every 15 minutes.", "what_it_shows": "The record described 15-minute checks, staff observations, agitation, unusual behavior, and communication about observation level after a suicide attempt in an inpatient psychiatric setting. The court affirmed judgment for the physician." }, { "case": "Jones v. State", "url": "https://www.courtlistener.com/opinion/1918969/jones-v-state/", "court": "District Court of Appeal of Florida", "year": "2005", "quote": "", "what_it_shows": "The opinion involved a psychiatric technician assigned to suicide watch checks while also assigned to continuous observation of another patient. The court reversed the neglect conviction; the separate record-falsification conviction was not appealed. In charting terms: do not document a check as completed if it was not completed." }, { "case": "Francis v. Northumberland County", "url": "https://www.courtlistener.com/opinion/2523206/francis-v-northumberland-county/", "court": "District Court, M.D. Pennsylvania", "year": "2009", "quote": "Lieut. Bruce placed Mr. Francis on close suicide watch (“close watch”), which entailed a cell check every 15 minutes.", "what_it_shows": "The opinion describes close suicide watch, documentation wording, and later confusion about whether suicide watch was still in place. Summary judgment for the psychiatrist was denied." }, { "case": "Estate of Wells v. Bureau County, District Court", "url": "https://www.courtlistener.com/opinion/2540432/estate-of-wells-v-bureau-county/", "court": "C.D. Illinois", "year": "2010", "quote": "During her checks, Keefer personally observed the detainees in two of the cells in Cellblock 2 because she could see them from the guard walkway, but did not observe Wells in his cell because she was unable to see into his cell from the guard walkway.", "what_it_shows": "The opinion describes checks where staff could not actually see the person in the cell. The motion for summary judgment was granted in part and denied in part." } ], "guidance": [ { "says": "When suicide precautions call for q15 checks, document q15 visual observation at the required interval, including when the patient is also under heightened monitoring.", "sources": [ { "name": "NCONL", "url": "https://www.nconl.org/assets/docs/NCONL%20Suicide%20Monitoring%20Precautions.pdf" }, { "name": "hospitalinspections.org", "url": "https://www.hospitalinspections.org/report-detail/XS2L11" } ] }, { "says": "Each observation entry should show the time, location, patient activity or behavior, and any immediate safety concern, or that no concern was observed.", "sources": [ { "name": "NurseChartingPro", "url": "https://nursechartingpro.com/guides/safety-assessment-charting" }, { "name": "VisibleHand", "url": "https://www.visiblehand.com/single-post/what-do-psych-hospitals-record-on-their-q15-sheets" } ] }, { "says": "Suicide precautions include reducing environmental access to items that could be used for self-harm. Your chart should show those safety actions.", "sources": [ { "name": "OpenStax", "url": "https://openstax.org/books/psychiatric-mental-health/pages/16-3-self-harm-and-suicide" }, { "name": "WTCS Pressbooks", "url": "https://wtcs.pressbooks.pub/nursingmhcc/chapter/1-6-safety/" } ] }, { "says": "Suicide-risk documentation should include current ideation status, plan or intent when assessed, means or access concerns, and the current observation or safety level.", "sources": [ { "name": "ICANotes", "url": "https://www.icanotes.com/2018/02/16/10-things-every-psychiatric-nurses-progress-note/" }, { "name": "NurseChartingPro", "url": "https://nursechartingpro.com/guides/psychiatric-nursing-charting" } ] } ], "ready_to_copy": "[DATE] [TIME] Suicide precautions observation note. Current order: [Q15 VISUAL CHECKS/1:1 CONTINUOUS OBSERVATION] per [PROVIDER NAME], ordered at [TIME]. Patient visually observed at [TIME] in [LOCATION]. Position/activity: [POSITION/ACTIVITY]. Behavior/affect: [BEHAVIOR]. Patient statements: [STATEMENT OR DENIES SI/PLAN/INTENT]. Visibility: [HANDS/FACE/NECK/RESPIRATIONS VISIBLE OR LIMITATION]. If resting: [EYES CLOSED, CHEST RISE VISIBLE, RESPIRATIONS EVEN/UNLABORED]. Environment check: [ROOM/BATHROOM/BEDDING/CORDS/TRASH/TRAY/BELONGINGS CHECKED]. Items removed or secured: [ITEMS OR NONE]. Staff assigned to observation: [NAME/ROLE]. Plan: continue [PRECAUTION LEVEL]; next check due [TIME].", "samples_are_written": true }, { "slug": "dose-missed-mar", "title": "When the Dose Was Given but the MAR Missed It", "search_title": "", "question": "How do I document the actual administration time, reason for a missed scan or manual entry, dose details, pain reassessment, and notifications when a medication was given but the MAR did not capture it?", "asked_as": "nurse forum forgot to scan narcotic medication given MAR documentation late entry", "cluster": "trouble", "url": "https://shiftiswild.com/notes/dose-missed-mar/", "markdown_url": "https://shiftiswild.com/notes/dose-missed-mar.md", "summary": "You gave the med. The barcode scan didn’t save, the eMAR click disappeared, or the MAR signature never stuck. Don’t chart around it. Fix the record so it shows what happened: the real administration time, why the scan or manual entry missed, the dose details, the patient response, and who you notified.", "key_points": [ "If the patient got the dose, don’t mark it as not given.", "Enter a late or manual MAR entry with the actual administration time, not the time you found the problem.", "Say why the scan or MAR entry failed: scanner failure, downtime, unreadable barcode, emergency workflow, wrong workstation, or another specific reason.", "Include dose details: medication, dose, route, site or rate if relevant, amount removed, amount administered, amount wasted or returned, and witness if required.", "For pain meds or sedating meds, add reassessment and notifications: pain score, sedation/respiratory status, effect, adverse effects, charge nurse/pharmacy/provider notice as applicable." ], "one_thing": "Chart when the medication actually went into the patient. Then say why the MAR didn’t catch it.", "what_goes_wrong": "The usual mistake is trying to make the MAR look clean instead of making it true. If you chart the scheduled 0900 time when the medication actually went in at 0947, you just created a false timeline. If you mark it not given, the next nurse may think the patient still needs it.\n\nThe note has to connect the dots: order, patient ID check, actual dose, actual time, reason the system missed it, patient response, and follow-up. If those pieces are scattered without a note tying them together, the dose can look unaccounted for, duplicated, late with no reason, or never reassessed.", "rewrites": [ { "situation": "", "before": "Med given. Scanner broken.", "after": "Late eMAR entry completed at 1038. Oxycodone 5 mg PO administered at 1012 for pain 8/10 per active PRN order. Bedside scan did not transmit after two attempts due to scanner error on WOW-3. Patient identified with name and DOB; medication verified against active MAR before administration." }, { "situation": "", "before": "Morphine scanned wrong.", "after": "Morphine 2 mg IV push administered at 1416 through left forearm PIV for pain 9/10. Unit-dose barcode unreadable; manual verification completed against active order and allergy list before administration. Charge RN A. Smith notified at 1425." }, { "situation": "", "before": "Wasted remainder.", "after": "Hydromorphone 1 mg/1 mL removed from ADC at 0754. Administered 0.4 mg IV push at 0801 per order. Wasted 0.6 mg in medication room with J. Lee, RN, witness, at 0804. ADC discrepancy reviewed and resolved with witness." }, { "situation": "", "before": "Pain better.", "after": "Pain reassessment at 0840 after hydromorphone: pain decreased from 8/10 to 3/10. RR 16, SpO2 96% on room air, POSS 1, patient awake and conversing, denies nausea or dizziness." }, { "situation": "", "before": "Provider aware.", "after": "Dr. Patel notified at 1120 that ceftriaxone 1 g IV was administered at 1045 but initial MAR scan did not save during downtime. Manual late entry completed. No new orders received." }, { "situation": "", "before": "Forgot to chart last night.", "after": "Late entry entered 06/14/2026 at 0715: Acetaminophen 650 mg PO was administered 06/13/2026 at 2220 for temp 100.8°F. MAR entry not completed at time of administration due to urgent transfer of another patient. Patient temp 99.4°F at 2325; no adverse reaction noted. Charge RN notified at 0718." } ], "words_to_avoid": [ { "wording": "Forgot", "why": "Sounds like a memory problem and does not tell what happened clinically", "instead": "Late entry. Dose administered at [TIME]. MAR did not capture because [REASON]." }, { "wording": "Scanner broken", "why": "Too vague; does not show what check was done", "instead": "Barcode scan failed after [NUMBER] attempts on [DEVICE]. Patient and medication verified manually against active MAR/order." }, { "wording": "Given as ordered", "why": "Leaves out dose, route, time, and patient response", "instead": "[MEDICATION] [DOSE] [ROUTE] administered at [TIME] for [INDICATION]." }, { "wording": "Wasted", "why": "Missing amount and witness", "instead": "[AMOUNT] wasted with [NAME/TITLE] at [TIME] per controlled substance process." }, { "wording": "Patient fine", "why": "Not a reassessment", "instead": "Pain [SCORE], RR [NUMBER], sedation [SCALE], BP [VALUE], response [DETAILS], adverse effects [YES/NO]." }, { "wording": "Charting error", "why": "Too broad", "instead": "eMAR capture failure, late MAR entry, duplicate scan attempt, barcode unreadable, downtime entry." }, { "wording": "I think", "why": "Adds uncertainty", "instead": "State only verified facts; if unsure, document what could not be verified and who was notified." } ], "cases": [ { "case": "Wilkin v. Community Hospital of the Monterey Peninsula", "url": "https://www.courtlistener.com/opinion/5298809/wilkin-v-community-hospital-of-the-monterey-peninsula/", "court": "California Court of Appeal", "year": "2021", "quote": "This discrepancy left four milligrams of morphine unaccounted for; Wilkin admitted at her deposition that such a discrepancy should have been documented.", "what_it_shows": "" }, { "case": "Heard v. Aultman Hosp.", "url": "https://www.courtlistener.com/opinion/3186301/heard-v-aultman-hosp/", "court": "Ohio Court of Appeals", "year": "2016", "quote": "The waste of the remaining morphine was not documented on the anesthesia record.", "what_it_shows": "" }, { "case": "Black v. Ohio Bd. of Nursing", "url": "https://www.courtlistener.com/opinion/9355865/black-v-ohio-bd-of-nursing/", "court": "Ohio Court of Appeals", "year": "2022", "quote": "You administered these drugs to the patient without documenting that you questioned the order(s) and/or consulted with any member of the health care team regarding the accuracy/validity of or harmfulness to the patient of these order(s).", "what_it_shows": "" }, { "case": "Gabriel v. County of Herkimer", "url": "https://www.courtlistener.com/opinion/8718656/gabriel-v-county-of-herkimer/", "court": "District Court, N.D. New York", "year": "2012", "quote": "The Narcotics List also indicates DiCamillo was administered an 8:30 p.m. dose of Clonazepam but this was not documented in the Security Log or the Medication Administration Record.", "what_it_shows": "" } ], "guidance": [ { "says": "If a dose is missed, refused, or not given as scheduled, don’t leave the MAR blank. Mark the MAR and document the reason in the right note or comment area.", "sources": [ { "name": "OpenStax", "url": "https://openstax.org/books/clinical-nursing-skills/pages/11-3-documentation-of-medication-administration" }, { "name": "Medicine LibreTexts", "url": "https://med.libretexts.org/Bookshelves/Nursing/Clinical_Nursing_Skills_(OpenStax" } ] }, { "says": "For a missed or refused medication, document the specific reason and follow facility policy for notifying the right person when notification is needed.", "sources": [ { "name": "Aplmed Academy", "url": "https://aplmed.com/registration-and-payments/qmap-training/qmap-online-course/4-documenting-medications-mar/4-4-documenting-on-the-medication-administration-record-mar/" }, { "name": "Unanswered.io", "url": "https://unanswered.io/guide/how-to-document-medication-administration-in-nursing-charts" } ] }, { "says": "For clinically significant missed or delayed medications, add a nursing note with follow-up. Don’t rely only on a MAR reason code.", "sources": [ { "name": "TheNewRN", "url": "https://thenewrn.com/wp-content/uploads/2026/05/Tipsheet_10_12_Missed_Medication_Documentation.pdf" }, { "name": "Unanswered.io", "url": "https://unanswered.io/guide/how-to-document-medication-administration-in-nursing-charts" } ] }, { "says": "Keep the record accurate. Don’t pre-document or sign in a way that does not match what actually happened.", "sources": [ { "name": "TheNewRN", "url": "https://thenewrn.com/wp-content/uploads/2026/05/Tipsheet_10_12_Missed_Medication_Documentation.pdf" }, { "name": "allnurses", "url": "https://allnurses.com/documentation-medication-missed-t762245/" } ] } ], "ready_to_copy": "Late MAR/eMAR clarification entered [DATE] at [TIME ENTERED]. [MEDICATION] [DOSE] [ROUTE] was administered to [PATIENT NAME/INITIALS] at [ACTUAL ADMINISTRATION TIME] for [INDICATION] per active order [ORDER DETAILS].\n\nMAR/barcode capture did not complete at time of administration because [SPECIFIC REASON]. Before administration, patient identity was verified using [TWO IDENTIFIERS]. Medication, dose, route, allergies, and timing were verified against the active MAR/order by [NAME/TITLE OR N/A].\n\nDose details: [AMOUNT REMOVED] removed from [ADC/OTHER] at [TIME REMOVED]; [AMOUNT ADMINISTERED] administered; [AMOUNT WASTED/RETURNED/N/A] [WASTED/RETURNED/N/A] with [WITNESS NAME/TITLE/N/A] at [TIME] per facility process.\n\nPre-dose assessment: [PAIN SCORE/VITALS/SEDATION/RELEVANT ASSESSMENT]. Reassessment at [TIME]: [PAIN SCORE/RESPONSE/VITALS/SEDATION/ADVERSE EFFECTS].\n\n[CHARGE RN/PHARMACY/PROVIDER] notified at [TIME]; response: [NO NEW ORDERS/NEW ORDERS/FOLLOW-UP]. Next dose timing reviewed and communicated to [NAME/TITLE] at [TIME].", "samples_are_written": true }, { "slug": "verbal-orders", "title": "Writing down verbal orders and the read-back line", "search_title": "Documenting a verbal order and the read-back", "question": "How do you write down an order given out loud?", "asked_as": "verbal order documentation nurse read back dispute", "cluster": "others", "url": "https://shiftiswild.com/notes/verbal-orders/", "markdown_url": "https://shiftiswild.com/notes/verbal-orders.md", "summary": "When a prescriber gives you an order at the bedside or over the phone, record what they ordered and who gave it. Make clear whether they confirmed your read-back. You're documenting an order, not just a conversation.", "key_points": [ "Check that you may accept the order. Follow your facility’s rules for your role, the setting, and the type of order.", "Use the designated order workflow. Include the date and time you received the order, the prescriber’s name and credentials, how they communicated it, and your identity as the receiving clinician. A progress note alone doesn't replace required order entry.", "Capture the complete instruction. For medication orders, include the medication, dose and units, route, timing or frequency, and any applicable indication or parameters. If something's missing, ask. Don't fill it in yourself.", "Read back what you recorded. Clear up uncertain names, numbers, and instructions with the prescriber. Document confirmation only if you got it.", "Keep read-back and authentication separate. Your read-back entry records the verification conversation. You still need to follow your facility’s prescriber-authentication workflow." ], "one_thing": "Write the complete order. Read it back. Document confirmation only if the prescriber actually confirmed it.", "what_goes_wrong": "The common mistake: you chart the contact but leave out the order. An entry such as *MD aware; medication ordered* doesn't tell the next person what medication to give, at what dose, by which route, or when.\n\n*VO/RB* won't fix that. The details are still missing. It also misrepresents what happened if you repeated the order but the call ended before the prescriber confirmed it.\n\nThe same goes for secure messages. A typed response isn't an order given out loud. Don't label a chat exchange as a verbal order or chart a verbal read-back that never happened. Use the communication and order-entry pathway your facility permits.", "rewrites": [ { "situation": "", "before": "Tylenol now per MD. RB.", "after": "09/12/2026 0915 — Verbal order from Maya Chen, MD: acetaminophen 650 mg orally once now for headache. Complete order read back to Dr. Chen; confirmed correct. Received and entered by J. Rivera, RN." }, { "situation": "", "before": "CBC in AM, TO.", "after": "09/12/2026 2030 — Telephone order from Elena Brooks, NP: Complete blood count without differential on 09/13/2026 at 0600. Complete order read back to E. Brooks, NP; confirmed correct. Received and entered by J. Rivera, RN." }, { "situation": "", "before": "VO/RB. Will clarify dose.", "after": "09/12/2026 1410 — Telephone call with Maya Chen, MD, regarding acetaminophen. Dose unclear; call disconnected before clarification or confirmed read-back. No acetaminophen administered. Callback attempted at 1412; no answer. Charge RN notified at 1415; covering prescriber contacted for clarification. J. Rivera, RN." }, { "situation": "", "before": "MD denying order. Not my error.", "after": "09/12/2026 1610 — Maya Chen, MD, stated she did not give the acetaminophen order entered at 1545. Medication not yet administered. Clarification of current treatment plan requested from Dr. Chen; charge RN notified at 1613. J. Rivera, RN." } ], "words_to_avoid": [ { "wording": "MD aware", "why": "Shows contact, not the instruction received.", "instead": "Prescriber’s name, communication method, and complete order—or the actual response if no order was given." }, { "wording": "VO/RB", "why": "Can hide whether an actual read-back and confirmation occurred. Abbreviation use also depends on facility policy.", "instead": "The approved order-type field plus a factual read-back confirmation entry." }, { "wording": "As usual / per routine", "why": "Leaves the next clinician to supply missing details.", "instead": "The specific dose, route, timing, and other instructions confirmed with the prescriber." }, { "wording": "Will sign later", "why": "Predicts a future action rather than documenting current status.", "instead": "Prescriber authentication pending; routed to [name] at [time], if accurate." }, { "wording": "MD denying it / not my fault", "why": "Mixes a communication record with defensiveness.", "instead": "What the prescriber stated, when, and what clarification or escalation followed." } ], "cases": [ { "case": "W. Frank Wells Nursing Home v. State, Agency for Health Care Administration", "url": "https://www.courtlistener.com/opinion/2492950/w-frank-wells-nursing-home-v-state-agency-for-health-care-administration/", "court": ", District Court of Appeal of Florida", "year": "2011", "quote": "", "what_it_shows": "The opinion drew a distinction between the first verbal order, for an emergency-room mental evaluation, and a later verbal order to transfer the resident to a state hospital. The court set aside the facility’s citation because the undisputed facts didn't establish the cited statutory violation. The scope of that first order mattered: a general mental evaluation wasn't the same instruction as an involuntary examination." }, { "case": "Watkins v. Central State Griffin Memorial Hospital", "url": "https://www.courtlistener.com/opinion/3215428/watkins-v-central-state-griffin-memorial-hospital/", "court": ", Supreme Court of Oklahoma", "year": "2016", "quote": "", "what_it_shows": "The record contained conflicting accounts of whether a physician had given an order before an examination. There was no written order for that examination in the chart. The court held that factual disputes involving allegedly withheld information made summary adjudication improper. The ruling concerned the claim deadline and disputed information. It didn't say that a particular read-back phrase would settle an order dispute." } ], "guidance": [ { "says": "In routine circumstances, record the complete order before you read it back to the prescriber.", "sources": [ { "name": "NCC MERP", "url": "https://www.nccmerp.org/recommendations-reduce-medication-errors-associated-verbal-medication-orders-and-prescriptions" }, { "name": "Basicmedical Key", "url": "https://basicmedicalkey.com/understanding-and-interpreting-medication-orders/" } ] }, { "says": "If you're receiving the order, you should read it back and get confirmation from the prescriber.", "sources": [ { "name": "WebM&M via NCBI", "url": "https://www.ncbi.nlm.nih.gov/books/NBK615865/" }, { "name": "NCC MERP", "url": "https://www.nccmerp.org/recommendations-reduce-medication-errors-associated-verbal-medication-orders-and-prescriptions" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "handoff", "title": "What the handoff note has to carry", "search_title": "What a nursing handoff note has to include", "question": "What has to be written down at shift change, and what gets lost?", "asked_as": "handoff report documentation failure communication nurse", "cluster": "others", "url": "https://shiftiswild.com/notes/handoff/", "markdown_url": "https://shiftiswild.com/notes/handoff.md", "summary": "The next nurse needs to know what needs attention now, without piecing together your whole shift. Give them the patient’s current condition, meaningful changes, and unfinished work. Say when the next step is due and who will handle it. Follow your facility’s documentation and handoff process; this is a practical checklist, not a universal legal requirement.", "key_points": [ "Make the current picture clear. Verify the patient’s identity and current alerts in the approved handoff tool: allergies, code status, precautions, and relevant support needs.", "Pass on meaningful changes. Say when the change happened, what you assessed, what you did, and how the patient responded. Point to the detailed event note when needed.", "Name what’s unfinished. List pending tests, reassessments, medication issues, and provider responses. Include what happens next, when, and who will follow up.", "Close the communication loop. Pass important information directly and leave room for questions. Document who actually received the handoff, when, and how, as required.", "Keep essential information in the approved record. Don’t leave it only on your worksheet, in someone’s memory, or in an outdated copied summary." ], "one_thing": "Write what changed, where the patient stands now, and what happens next. Include when and who.", "what_goes_wrong": "Writing that you gave report is not the same as writing what still needs attention.\n\n*Report given; patient stable* tells you an exchange happened. It doesn’t tell the next nurse whether the patient recently became dizzy, a specimen still needs collecting, or a provider has responded.\n\nOften, the details are there. The connections are missing:\n\n- **A number without a trend:** Was that blood pressure usual for this patient or a new change?\n- **An intervention without a response:** Did the symptom improve, persist, or return?\n- **A pending item without a stage:** Was the test ordered, collected, resulted, or reviewed?\n- **A notification without an answer:** Did you send a message, or did a conversation produce a plan?\n- **A task without responsibility:** Did anyone actually agree to follow it up?\n\nYou don’t necessarily need more text. The medication administration record, flowsheets, orders, and event notes already hold the details. Use the handoff to show what changed, where things stand, and what comes next. Don’t copy the whole chart.\n\nThe written record keeps the details available. The conversation gives the receiving nurse a chance to clarify them. Neither replaces assessing the patient.", "rewrites": [ { "situation": "", "before": "Patient stable. No issues.", "after": "1845: BP 110/68, HR 88. Denies dizziness at rest. At 1745, developed dizziness when standing; assisted back to bed. See 1755 event note for assessment, provider communication, and interventions. Assisted ambulation remains in current care plan. Change and current status reviewed with A. Patel, RN, at 1900." }, { "situation": "", "before": "Labs pending.", "after": "1900: CBC ordered for 2000; specimen not yet collected. A. Patel, RN, confirmed collection and result follow-up during handoff." }, { "situation": "", "before": "MD aware of low urine output.", "after": "1840: Dr. Lee paged regarding urine output of 90 mL from 1500–1840. No response received by 1900. Charge RN M. Chen notified at 1855. Pending response and need for continued escalation under unit protocol reviewed with A. Patel, RN, at 1900." }, { "situation": "", "before": "Pain medication given. Continue to monitor.", "after": "1840: Acetaminophen 650 mg PO administered per PRN order for headache rated 6/10; see MAR. Pain reassessment due at 1940 under unit protocol remains outstanding at handoff. A. Patel, RN, confirmed reassessment follow-up." }, { "situation": "", "before": "Up with assist.", "after": "1830: Required one-person assistance and walker for transfer from bed to chair; became unsteady when turning. Instructed to call before standing; call light within reach. Current transfer needs reviewed with A. Patel, RN, at 1900." }, { "situation": "", "before": "Report given to nights.", "after": "1915: Telephone handoff completed with A. Patel, RN, after missed shift-end report. Reviewed dizziness episode, current transfer assistance, and 2000 CBC collection and result follow-up. A. Patel confirmed these follow-up items." } ], "words_to_avoid": [ { "wording": "Stable", "why": "Hides the assessment and comparison point.", "instead": "BP 110/68 at 1845; denies dizziness at rest." }, { "wording": "MD aware", "why": "Does not distinguish a page from a response or plan.", "instead": "Dr. Lee paged at 1840; no response by 1900." }, { "wording": "Labs pending", "why": "Could mean several different stages.", "instead": "CBC due 2000; specimen not yet collected." }, { "wording": "Continue to monitor", "why": "Does not identify the observation or timing.", "instead": "Pain reassessment due 1940 under unit protocol; A. Patel, RN, confirmed follow-up." }, { "wording": "See chart", "why": "Gives no destination or reason to look.", "instead": "See 1755 event note for dizziness assessment and interventions." }, { "wording": "Report given", "why": "Does not identify the recipient or unresolved items transferred.", "instead": "Telephone handoff to A. Patel, RN, at 1915; CBC collection and result follow-up reviewed." } ], "cases": [ { "case": "Francis v. Delaware Board of Nursing", "url": "https://www.courtlistener.com/opinion/4462017/francis-v-delaware-board-of-nursing/", "court": "Superior Court of Delaware", "year": "2018", "quote": "", "what_it_shows": "During a shift-change medication count, a nurse spilled 12 Sovaldi tablets, discarded them into a sharps container, and recorded the disposal on a usage log. The opinion describes a later log update after the tablets were retrieved and returned to the bottle. What the pharmacists knew and how they took part in the decision became disputed issues in the disciplinary proceedings. The court reversed the Board’s disciplinary decision because it found insufficient evidence to support it. The supplied text does not say the log led to that reversal. This was a disciplinary appeal, not a ruling on required handoff-note fields. Don’t read it as a clinical recommendation to retrieve or reuse discarded medication." } ], "guidance": [ { "says": "Make changes in the patient’s condition easy for the incoming nurse to find.", "sources": [ { "name": "VitaWerks", "url": "https://www.vitawerks.com/blog/how-to-effectively-file-a-nursing-shift-change-report/" }, { "name": "Nursebrain", "url": "https://nursebrain.com/blog/nurse-charting-101-tips-chart-faster/" } ] }, { "says": "Put pending work in the next-shift plan. Don’t end the summary with only the care you completed.", "sources": [ { "name": "NurseChartingPro", "url": "https://nursechartingpro.com/guides/summary-narrative-charting" }, { "name": "Nursebrain", "url": "https://nursebrain.com/blog/nurse-charting-101-tips-chart-faster/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "patient-abuse-disclosure", "title": "Charting a patient’s report of sexual abuse by a staff member", "search_title": "Charting a patient's report of abuse by staff", "question": "How do I document a patient's disclosure of sexual abuse by a staff member, preserving their exact words, whether the disclosure was spontaneous or prompted, and the immediate safety measures taken?", "asked_as": "(site:allnurses.com OR site:reddit.com/r/nursing) documenting patient disclosure sexual abuse staff exact words nursing notes", "cluster": "others", "url": "https://shiftiswild.com/notes/patient-abuse-disclosure/", "markdown_url": "https://shiftiswild.com/notes/patient-abuse-disclosure.md", "summary": "A patient tells you a staff member touched them sexually, threatened them, or did something sexual during care. Your note has three jobs: keep the patient’s words intact, show whether they said it on their own or after you asked, and show what you did right away to keep them safe.", "key_points": [ "Start with the time, place, who was there, and what was happening when the patient spoke.", "Use the patient’s exact words in your facility’s verbatim format. Slang, body words, profanity: include them if they matter clinically.", "If you asked a question first, chart your question and the answer. If the patient said it without being asked, chart that it was spontaneous.", "Keep what you saw separate from what the patient reported.", "Chart the immediate safety steps: remove the named staff member from care, notify the chain of command, stay with the patient as needed, offer SANE/forensic resources, and follow facility reporting policy." ], "one_thing": "Chart the exact words, how they came out, and what you did right away to keep the patient safe.", "what_goes_wrong": "The usual bad note is a tidy little summary like patient claims abuse by aide. It feels efficient. It also strips out the parts people need later: the patient’s actual words, whether you prompted the disclosure, who was there, and what you did for safety.\n\nThe mechanics matter. If you don’t chart what you asked, the next person can’t tell whether the patient spoke up on their own or answered a leading question. If you write your own conclusion, the note can sound like you’re deciding what legally happened. That’s not the job. Chart what the patient reported and what you observed. If you leave out the safety actions, the record doesn’t show how the team protected the patient after the disclosure.", "rewrites": [ { "situation": "", "before": "Pt claims CNA sexually abused her. Supervisor aware.", "after": "0815 During incontinence care, patient became tearful and stated verbatim: CNA J.M. put his hand inside my brief last night and rubbed me between my legs. I told him stop. Disclosure was spontaneous; this RN had not asked about sexual contact or staff conduct before statement. Patient alert and oriented to person, place, date, and situation. Perineal care paused; second RN K.P. present from 0817. Patient covered, door closed. Charge RN notified 0819; house supervisor notified 0822. Staff member J.M. removed from patient assignment per charge RN. Patient requested female staff only for personal care; care team updated. Provider, social work, and SANE resource notified per policy." }, { "situation": "", "before": "Pt says night tech touched her after I asked if she was assaulted.", "after": "2134 Patient pulled blanket to chest and stated she did not want tech R.L. in room. RN asked: Do you feel unsafe with R.L. helping you tonight? Patient stated verbatim: Yes. He touched my breasts when he was putting on my gown. Disclosure followed safety question after patient objected to staff entering room. Tech R.L. left room. Charge RN notified and reassigned tech R.L. away from patient care. Patient agreed to move to room closer to nurses’ station; moved at 2150. Provider and house supervisor notified." }, { "situation": "", "before": "Pt using vulgar language and making accusations against aide.", "after": "1402 Patient stated verbatim: The aide said he was going to fuck me in my ass and grabbed my butt. Patient crying, hands shaking, voice raised. No threat toward staff voiced by patient. RN remained with patient until charge RN arrived at 1406. Patient identified aide as evening-shift aide M.T. Staff member named by patient not assigned to room after notification to charge RN. Second staff member assigned for all personal care." }, { "situation": "", "before": "No evidence of sexual assault found.", "after": "0025 With patient consent and RN L.S. present, external skin check completed during hygiene. No visible redness, bleeding, bruising, or tearing seen on external perineal skin. Patient continued to state verbatim: He put his fingers inside me. Patient offered SANE/forensic exam and stated she wants exam. Full bath deferred pending SANE guidance per policy. Provider and SANE resource notified." }, { "situation": "", "before": "Patient refuses all care from male staff and is manipulative.", "after": "0630 Patient declined male staff for bathing and transfer after reporting sexual touching by staff member on night shift. Patient stated she feels safer with female staff. Female RN and PCT assigned for personal care this shift. Patient accepted vital signs, medications, wound care, and breakfast setup from female RN." }, { "situation": "", "before": "Patient is confused and probably misinterpreted care.", "after": "1710 Patient with documented dementia, oriented to self and hospital, not oriented to date. During brief change, patient stated verbatim: That man put his hand in me last night. Disclosure was spontaneous during care. Patient unable to give staff name when asked: Do you know the person’s name? Patient stated verbatim: I don’t know. Charge RN and provider notified. Male staff removed from personal care pending supervisor review. Patient placed in room visible from nurses’ station; frequent rounding initiated." } ], "words_to_avoid": [ { "wording": "claims", "why": "Sounds like you don’t believe the patient", "instead": "reports, states, disclosed" }, { "wording": "alleged victim", "why": "Legal language, and it creates distance", "instead": "patient, patient who reported sexual contact" }, { "wording": "accused aide abused patient", "why": "That’s your conclusion, unless you witnessed it", "instead": "patient reported sexual touching by staff member" }, { "wording": "rape or sexual assault as your own label", "why": "Can read like a legal conclusion", "instead": "patient reported nonconsensual sexual contact; preserve patient’s own word if they used it" }, { "wording": "admits", "why": "Makes it sound like the patient did something wrong", "instead": "states, reports" }, { "wording": "refuses", "why": "Can make the patient sound oppositional", "instead": "declined, did not consent, requested not to" }, { "wording": "no evidence of abuse", "why": "Says more than you know", "instead": "no visible injury noted on assessment" }, { "wording": "inappropriate relationship", "why": "Too vague, and it can shift blame onto the patient", "instead": "describe the reported contact or observed behavior" }, { "wording": "patient is unreliable", "why": "Judgmental, not specific", "instead": "document orientation, cognition, speech, affect, and exact statement" }, { "wording": "staff denies it", "why": "Usually belongs in investigation channels, not the clinical note", "instead": "chart patient safety actions and required notifications" } ], "cases": [ { "case": "State v. Wright", "url": "https://www.courtlistener.com/opinion/4674624/state-v-wright/", "court": "Ohio Court of Appeals", "year": "2019", "quote": "", "what_it_shows": "The nurse who performed the rape-kit exam described the history as being “able to get in their own words exactly what happened at that time that they remember.”" }, { "case": "Jesus Mendez v. State", "url": "https://www.courtlistener.com/opinion/4868779/jesus-mendez-v-state/", "court": "Texas Court of Appeals, 3rd District", "year": "2021", "quote": "", "what_it_shows": "The appellate record included SANE testimony about the exam, what the patient told the SANE, and a written statement made during the exam" }, { "case": "Jose Azael Zambrano-Perez v. the State of Texas", "url": "https://www.courtlistener.com/opinion/9452853/jose-azael-zambrano-perez-v-the-state-of-texas/", "court": "Texas Court of Appeals, 14th District", "year": "2023", "quote": "", "what_it_shows": "The appeal challenged testimony and statements in medical records; the judgment was affirmed" }, { "case": "State v. Brook", "url": "https://www.courtlistener.com/opinion/10038550/state-v-brook/", "court": "Ohio Court of Appeals", "year": "2024", "quote": "", "what_it_shows": "The record included SANE examination testimony and histories given by the patients during those exams" } ], "guidance": [ { "says": "Keep the patient’s own wording. Don’t clean it up or swap body words for polite language.", "sources": [ { "name": "RCN", "url": "https://www.rcn.org.uk/-/media/royal-college-of-nursing/documents/clinical-topics/mental-health/rachel-luby-disclosures-of-sexual-violence.pdf?la=en&hash=795ED5602DE53E7F21A22B215B696EED" }, { "name": "Study.com", "url": "https://study.com/academy/lesson/mandated-reporting-in-nursing-identifying-reporting-patient-abuse.html" } ] }, { "says": "Separate what the patient reported from what you observed. Don’t turn the note into a legal conclusion about what happened.", "sources": [ { "name": "ICANotes", "url": "https://www.icanotes.com/2026/04/27/sexual-trauma-therapy-response-treatment-documentation/" }, { "name": "Study.com", "url": "https://study.com/academy/lesson/mandated-reporting-in-nursing-identifying-reporting-patient-abuse.html" } ] }, { "says": "Chart the clinical response: safety steps, privacy concerns, interventions offered, notifications, and who was present when it matters.", "sources": [ { "name": "BUMC", "url": "https://www.bumc.bu.edu/gimcovid/files/2021/01/Abuse-Documentation-Guide-2020.pdf" }, { "name": "NeuroLaunch", "url": "https://neurolaunch.com/how-to-document-inappropriate-patient-behavior/" } ] }, { "says": "Use your facility’s SANE or medical-forensic pathway when the patient meets criteria. Don’t try to handle the forensic exam on your own.", "sources": [ { "name": "Mass.gov", "url": "https://www.mass.gov/doc/sane-section-ii-roles-and-responsibilities-0/download" }, { "name": "Texas Evidence Collection Protocol", "url": "https://tecp.forensic-nursing.tamu.edu/protocol/protocol/medical-forensic-assessment-documentation/sexual-assault-medical-forensic-assessment/" } ] }, { "says": "Follow facility policy and local reporting rules for child, elder, sexual abuse, or abuse of an at-risk person. Chart what you saw, heard, and did.", "sources": [ { "name": "Medicine LibreTexts", "url": "https://med.libretexts.org/Bookshelves/Nursing/Clinical_Nursing_Skills_(OpenStax" }, { "name": "Study.com", "url": "https://study.com/academy/lesson/mandated-reporting-in-nursing-identifying-reporting-patient-abuse.html" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "law-enforcement-requests", "title": "When Police Ask for Blood or Records", "search_title": "When police ask for patient information", "question": "What do I document when law enforcement requests a specimen, records, or access to a patient and consent or legal authority is not clear?", "asked_as": "nurse forum police request blood draw warrant consent what to chart", "cluster": "others", "url": "https://shiftiswild.com/notes/law-enforcement-requests/", "markdown_url": "https://shiftiswild.com/notes/law-enforcement-requests.md", "summary": "If an officer asks for blood, records, or access to a patient, and you are not clear on consent or legal authority, don’t try to argue the law in your note. That is not the job of the chart.\nWrite what happened. Who asked. What they asked for. What paperwork you saw, or did not see. Who you called. What you released. What you did not release.", "key_points": [ "Chart facts, not legal opinions: who asked, what they asked for, when they asked, and what they showed you.", "Document the patient’s condition and consent status: alert, unconscious, sedated, refusing, unable to participate, or asking not to speak.", "If someone hands you paperwork, describe the title on it: search warrant, subpoena, court order, authorization form. Don’t chart that it was valid unless that is actually your call.", "If the request is unclear, move it up the chain: charge nurse, supervisor, privacy/HIM, risk, security, or provider, based on policy. Then chart who you notified.", "If you release a specimen or records, chart the handoff: exact item, time, recipient, badge/agency if available, labels, seals, forms, and the condition of the specimen or packet." ], "one_thing": "Chart the request, what authority was shown or not shown, who you notified, and exactly what you did or did not release.", "what_goes_wrong": "The usual mistake is charting the drama instead of the trail.\n\nNotes like police demanded blood, illegal request, forced draw, or HIPAA says no may feel clear in the moment. Later, they are not enough. Was the patient able to consent? Did anyone ask? What document did law enforcement bring? Who reviewed it? Did anything actually leave the unit? Who had the specimen next?\n\nThe other mistake is barely charting anything. Blood to police. Records given to officer. That leaves out chain of custody, what authority staff relied on, and who made the decision. If someone questions the blood, the records, or the officer’s access later, your note should let them rebuild the event without guessing.", "rewrites": [ { "situation": "", "before": "Police wanted blood. Patient unconscious. I told them no without a warrant.", "after": "2240 Officer J. Smith, badge 123, City PD, requested blood specimen for law-enforcement testing. Patient intubated and sedated, RASS -4, unable to participate in consent discussion at this time. No warrant, court order, subpoena, or patient authorization presented to this RN. Charge RN M. Lee notified 2243; house supervisor A. Patel notified 2246. No law-enforcement specimen collected by this RN at this time. Medical care continued per ED orders." }, { "situation": "", "before": "Forced blood draw done per police.", "after": "0110 Officer B. Hall, badge 778, County Sheriff, presented document titled search warrant for blood specimen. Charge RN and house supervisor notified before collection. Patient awake, alert, and stated he did not want blood drawn. Provider notified of patient statement. Per facility process, specimen collected by phlebotomist R. Torres using sealed law-enforcement kit 24-1886, right antecubital venipuncture, iodine prep, gray-top tubes x2, tubes inverted and sealed. Specimen remained with R. Torres until handed to Officer Hall at 0128 with chain-of-custody form signed." }, { "situation": "", "before": "Gave labs to detective.", "after": "1435 Caller identified self as Detective L. Brown, City PD, and requested toxicology results by phone. No written request, subpoena, warrant, court order, or patient authorization received on unit at time of call. Caller directed to HIM/privacy office per facility policy. No lab values, diagnoses, medication list, or visit details disclosed by this RN. Charge RN notified 1440." }, { "situation": "", "before": "Subpoena came. Chart copied for police.", "after": "1610 Officer K. Nguyen, badge 455, delivered document titled subpoena addressed to medical records for ED visit dated 05/03/2026. Document sent to HIM/privacy office per facility policy. No records printed or released from ED by this RN. HIM confirmation received 1622. Charge RN aware." }, { "situation": "", "before": "Police interviewed patient.", "after": "1902 Officer D. Allen, badge 310, requested bedside access to speak with patient. Patient alert and oriented x4, receiving wound care, pain 8/10, and stated she did not want visitors at this time. Officer informed patient unavailable for interview at this time due to care needs and patient preference. Provider, charge RN, and security notified. No interview occurred in room during this RN’s care period." }, { "situation": "", "before": "Officer said hold fluids until blood draw.", "after": "1204 Officer M. Price requested IV fluids be delayed pending law-enforcement blood draw. Treating PA notified immediately. IV fluids administered at 1206 per existing medical order due to tachycardia and dehydration. Charge RN notified. No provider order received to delay fluids." }, { "situation": "", "before": "Blood tube sent with police.", "after": "0232 Law-enforcement specimen kit 24-2210 sealed at bedside. Tubes labeled with patient identifiers, date/time of collection, collector initials, and kit number. Seal intact at time of handoff. Kit handed directly to Officer S. Reed, badge 602, State Patrol, at 0236. Chain-of-custody form signed by collector and Officer Reed. Copy placed per unit process." }, { "situation": "", "before": "Patient has warrants, police notified.", "after": "0830 During triage, officer at nurses station asked whether patient was present in ED. No patient condition, location, diagnosis, treatment, or discharge plan disclosed by this RN. Charge RN and security notified of request. Request referred to supervisor per facility policy." } ], "words_to_avoid": [ { "wording": "Illegal request", "why": "Legal conclusion; does not say what happened", "instead": "No warrant, subpoena, court order, or authorization presented to this RN" }, { "wording": "Forced blood draw", "why": "Loaded phrase; unclear who authorized, who collected, and how", "instead": "Specimen collected after document titled search warrant was presented and supervisor notified" }, { "wording": "Police ordered me to", "why": "Makes it sound like law enforcement directed nursing care", "instead": "Officer requested; provider or supervisor notified; care provided per medical order" }, { "wording": "HIPAA says no", "why": "Too broad and may be wrong depending on process", "instead": "Request routed to HIM/privacy per facility policy; no PHI disclosed by this RN" }, { "wording": "Patient in custody, no consent needed", "why": "Legal conclusion and may skip patient status", "instead": "Patient in officer custody; patient alert and refused blood draw; supervisor notified" }, { "wording": "Cleared by warrant", "why": "You may not be the person who determines legal sufficiency", "instead": "Document titled search warrant presented; copy sent to supervisor/HIM/privacy" }, { "wording": "Gave records", "why": "Too vague", "instead": "Released sealed packet from HIM to Officer name, badge, agency, time, per release process" }, { "wording": "Blood to police", "why": "Missing chain of custody", "instead": "Kit number, tubes, seals, collector, time, recipient, badge, chain-of-custody form" }, { "wording": "Uncooperative", "why": "Judgment word; not specific", "instead": "Patient pulled arm away, declined venipuncture, or unable to remain still" }, { "wording": "Refused police", "why": "Vague; police are not the treatment", "instead": "Patient declined blood draw or patient declined to speak with officer" } ], "cases": [ { "case": "John Goodman v. Florida Department of Law Enforcement", "url": "https://www.courtlistener.com/opinion/4464114/john-goodman-v-florida-department-of-law-enforcement/", "court": "Supreme Court of Florida", "year": "2018", "quote": "Every blood analyst in this record testified that if a sample had an issue with clotting it would be noted on the laboratory file.", "what_it_shows": "The opinion discussed the blood draw method, the needle used, clotting concerns, and how irregularities would be documented in the lab file" }, { "case": "STATE OF FLORIDA v. ROBERT THOMAS TAVENESE", "url": "https://www.courtlistener.com/opinion/4886377/state-of-florida-v-robert-thomas-tavenese/", "court": "District Court of Appeal of Florida", "year": "2021", "quote": "Finally, we note HIPAA does not prevent the State from subpoenaing relevant medical records in a criminal proceeding, contrary to Respondent’s argument at the hearing.", "what_it_shows": "This one dealt with emergency room records and toxicology reports sought by subpoena after a DUI-related crash" }, { "case": "State v. Romano", "url": "https://www.courtlistener.com/opinion/4679564/state-v-romano/", "court": "Court of Appeals of North Carolina", "year": "2019", "quote": "Before accepting the blood sample, Sergeant Fowler attempted to get defendant’s consent to the blood draw or receipt of the evidence, but she was unable to wake him.", "what_it_shows": "The record described an impaired-driving patient, an attempted consent discussion, a blood sample, and later use of hospital medical records" }, { "case": "State v. Adam Rowell", "url": "https://www.courtlistener.com/opinion/6447180/state-v-adam-rowell/", "court": "Court of Appeals of South Carolina", "year": "2022", "quote": "Smith did not remember receiving this sample specifically because of the large number of specimens he regularly tested.", "what_it_shows": "Timing mattered here. So did the audit trail, who handled the specimen, and the normal hospital process after the blood sample was challenged" } ], "guidance": [ { "says": "Disclosures of health records or PHI to law enforcement need to be documented in the patient record or through your facility’s required disclosure process.", "sources": [ { "name": "Minnesota Statutes § 144.293", "url": "https://www.revisor.mn.gov/statutes/cite/144.293" }, { "name": "AHA", "url": "https://www.aha.org/system/files/2018-03/guidelinesreleasinginfo.pdf" } ] }, { "says": "For law-enforcement requests for records or PHI, use the written-request and documentation process. Don’t release information from an informal phone call or bedside request.", "sources": [ { "name": "MagMutual", "url": "https://www.magmutual.com/healthcare-insights/article/law-enforcement-exception-hipaa-what-providers-need-know" }, { "name": "WSHA", "url": "https://www.wsha.org/webfoo/wp-content/uploads/law-enforcement-guide-2023-9.7.23-1.pdf" } ] }, { "says": "If consent or authority for a specimen or evidence request is unclear, chart what authority was shown: patient consent, warrant, guardian authorization, or other facility-approved paperwork. Then escalate per policy.", "sources": [ { "name": "Nursing CE Central", "url": "https://nursingcecentral.com/lessons/collecting-and-preserving-evidence-in-healthcare-setting/" }, { "name": "WSHA", "url": "https://www.wsha.org/webfoo/wp-content/uploads/law-enforcement-guide-2023-9.7.23-1.pdf" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "chaperone-intimate-care", "title": "Charting Chaperones During Intimate Care", "search_title": "Documenting a chaperone during intimate care", "question": "What do I document when providing peri care, a skin check, a search, or other sensitive care where a chaperone or witness is present or offered?", "asked_as": "nurse forum document chaperone intimate care peri care patient allegation", "cluster": "others", "url": "https://shiftiswild.com/notes/chaperone-intimate-care/", "markdown_url": "https://shiftiswild.com/notes/chaperone-intimate-care.md", "summary": "Peri care, skin checks, pelvic or rectal exams, catheter care, bed baths, and safety searches are routine. They are also sensitive. Your note needs to show what you explained, who was present or offered, what the patient chose, and what you actually did.", "key_points": [ "Before sensitive care, tell the patient what you are about to do. If the patient can participate, get permission.", "Chart the chaperone or witness by name and role. Say whether they stayed for the whole care event or only part of it.", "If you offered a chaperone and the patient declined, chart that the patient declined after the offer.", "Chart privacy steps: door closed, curtain pulled, drape or bath blanket used, visitors asked to step out, patient preference honored.", "For searches, chart the policy-based reason, scope of search, witness, patient response, items found, and where the items went." ], "one_thing": "Chart the offer, the patient’s response, the chaperone or witness by name and role, and what actually happened.", "what_goes_wrong": "The bad note is usually too bare: Peri care done. Skin check done. Search completed. Chaperone present.\n\nThat does not mean the care was wrong. It means the note leaves the next reader guessing. Was the care explained? Did the patient agree or decline? Was a chaperone offered? Who was present? Did that person stay the whole time? What areas were assessed? What did the patient do or say? Was privacy protected?\n\nSensitive care notes do not need drama. They need clean mechanics: time, reason, explanation, patient response, chaperone or witness, privacy, objective findings, and follow-up.", "rewrites": [ { "situation": "", "before": "Peri care done.", "after": "0830 Peri care explained after urinary incontinence. Patient gave verbal permission. Chaperone offered and accepted. M. Lopez, CNA, present throughout and assisted with turning. Door closed, curtain pulled, bath blanket used. Peri care completed, barrier cream applied to intact perineal skin. Patient denied pain or distress." }, { "situation": "", "before": "Foley care done. Chaperone refused.", "after": "1330 Foley and peri care explained, including offer of staff chaperone. Patient declined chaperone and gave permission for this RN to proceed. Door closed, curtain pulled. Foley care completed. Catheter secured to right thigh, tubing without kinks, urine clear yellow. Perineal skin intact with mild redness to bilateral groin folds; barrier cream applied. Patient tolerated care." }, { "situation": "", "before": "Skin check done with CNA.", "after": "1015 Admission skin check explained. Patient requested female staff for breast, groin, and buttock assessment. Request honored. A. Nguyen, RN, and S. Patel, CNA, present throughout. Door closed, curtain pulled, patient covered except area being assessed. Skin assessed to under breasts, abdomen folds, groin, buttocks, sacrum, heels, elbows. Sacrum pink and blanchable; no open areas noted. Patient asked to pause for repositioning; care paused and resumed after patient agreed." }, { "situation": "", "before": "Male nurse did peri care with female chaperone.", "after": "0610 Patient requested female staff for peri care. Request honored. L. Rivera, CNA, provided peri care while this RN remained outside curtain and available for supplies. Skin intact; barrier cream applied by CNA. Patient calm, denied pain, call light within reach." }, { "situation": "", "before": "Pelvic exam chaperoned.", "after": "1542 Pelvic exam performed by Dr. Kim after provider explanation. Patient gave verbal permission. This RN present as chaperone for entire exam. Door closed, curtain pulled, patient draped. Patient reported cramping during exam; provider paused. Exam resumed after patient agreed. Specimens labeled at bedside and sent to lab." }, { "situation": "", "before": "Search negative.", "after": "2210 Belongings and skin safety search completed on admission per unit protocol after explanation to patient. Patient agreed to search. K. Brooks, RN, witnessed entire search. Patient changed into hospital gown behind closed door with curtain pulled. Clothing pockets, waistband, socks, and shoes checked. No body-cavity search performed. One vape pen found in jacket pocket, placed in security bag 123456; receipt given to patient. No other prohibited items found. Patient calm and cooperative." }, { "situation": "", "before": "Patient refused bath and was rude.", "after": "0735 Offered bed bath and peri care after bowel movement. Explained skin-protection reason and offered chaperone. Patient declined full bath at this time and requested to rest until 0900. Patient agreed to brief change and peri care only. Brief changed, peri area cleansed, barrier cream applied. Charge nurse notified; full bath to be reoffered at 0900." }, { "situation": "", "before": "Chaperone unavailable.", "after": "0240 Patient incontinent of stool with sacral dressing soiled. Explained need for prompt peri care and dressing change. Patient requested second staff member. Care delayed 8 minutes while charge RN arranged T. White, RN, to attend. T. White present throughout. Peri care completed and sacral dressing changed per order. Patient tolerated care and denied pain." } ], "words_to_avoid": [ { "wording": "Chaperone refused", "why": "Ambiguous. It can sound like staff refused to provide one.", "instead": "Patient declined chaperone after offer." }, { "wording": "Witness present", "why": "Too vague. It does not say who, role, or how long.", "instead": "M. Lopez, CNA, present throughout peri care." }, { "wording": "Peri care done", "why": "Leaves out explanation, permission, privacy, chaperone, and findings.", "instead": "Peri care explained; patient agreed; chaperone offered or present; care completed; skin findings charted." }, { "wording": "Skin check okay", "why": "Not objective. It does not tell what was checked.", "instead": "Sacrum, buttocks, groin, heels assessed; no open areas noted." }, { "wording": "Patient tolerated well", "why": "Fine as a closer, but weak by itself.", "instead": "Patient denied pain, no guarding or tearfulness noted, care completed." }, { "wording": "Patient inappropriate", "why": "A label, not a chartable behavior.", "instead": "Patient placed hand on staff wrist during peri care; staff redirected hand to bedrail; second staff called to room." }, { "wording": "Female chaperone for my protection", "why": "Centers the note on staff fear and can sound accusatory.", "instead": "Chaperone offered for patient comfort and privacy per unit practice; patient accepted." }, { "wording": "Search negative", "why": "Does not show scope, witness, or item handling.", "instead": "Safety search completed per policy with K. Brooks, RN, present; no prohibited items found." }, { "wording": "Patient refused touch", "why": "Too broad for care planning.", "instead": "Patient declined peri care at 0700; skin-risk reason explained; care reoffered for 0900; charge nurse notified." } ], "cases": [ { "case": "**Sobalvarro v. Vibra Health Care**", "url": "https://www.courtlistener.com/opinion/10826988/sobalvarro-v-vibra-health-care/", "court": "California Court of Appeal", "year": "2026", "quote": "", "what_it_shows": "A patient who was unable to move or speak alleged sexual assault during a hospitalization where a CNA provided peri care and bed baths. The jury found negligence against the hospital entities. The trial court granted judgment notwithstanding the verdict, and the appellate court reversed. The record included evidence about intimate care assignments, whether patient preferences about male or female attendants were asked, and family observations around closed-door changing" }, { "case": "**Department of Human Services v. Hale**", "url": "https://www.courtlistener.com/opinion/2514386/department-of-human-services-v-hale/", "court": "Hawaii Intermediate Court of Appeals", "year": "2008", "quote": "", "what_it_shows": "A neglect investigation involved Foley care, vaginal or perineal monitoring, the resident’s condition on hospital arrival, and documentation. After an administrative hearing, the hearing officer found that the facility did not abuse or neglect the resident. The appellate court reversed the circuit court and held that substantial evidence supported the hearing officer’s determination" }, { "case": "**Hart v. Celaya**", "url": "https://www.courtlistener.com/opinion/2510963/hart-v-celaya/", "court": "District Court, N.D. California", "year": "2008", "quote": "", "what_it_shows": "In a prison setting involving an unclothed body search and decontamination, the record discussed policy, timing, who was present, the search steps, and holding-cell welfare logs. The court granted summary judgment for the defendants" } ], "guidance": [ { "says": "For intimate or sensitive exams, document the chaperone’s identity. If the patient declined after the offer, document that too.", "sources": [ { "name": "PMC", "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC9844066/" }, { "name": "MICA", "url": "https://www.mica-insurance.com/blog/posts/the-use-of-chaperones-during-physical-exams/" } ] }, { "says": "Offer a chaperone for intimate examinations, and make the offer part of the record when the patient accepts or declines.", "sources": [ { "name": "Ovid", "url": "https://www.ovid.com/jnls/annals-of-medicine-and-surgery/fulltext/10.1016/j.amsu.2016.03.005~an-audit-on-the-use-of-chaperones-during-intimate-patient" }, { "name": "Weill Cornell", "url": "https://physicianorganization.weill.cornell.edu/system/files/procedures_file/wcm-pi-002_use_of_medical_chaperones_9.23.pdf" } ] }, { "says": "Chart the discussion of the sensitive procedure, the patient’s permission or consent process, and who served as chaperone.", "sources": [ { "name": "JOGNN", "url": "https://www.jognn.org/article/S0884-2175(21" }, { "name": "MICA", "url": "https://www.mica-insurance.com/blog/posts/the-use-of-chaperones-during-physical-exams/" } ] }, { "says": "For skin checks, document objective skin findings and the patient’s specific response so the note gives the next person a usable baseline.", "sources": [ { "name": "Washington DSHS", "url": "https://www.dshs.wa.gov/sites/default/files/ALTSA/hcs/documents/SOP%20Sample%20Documentation.doc" }, { "name": "Medline", "url": "https://www.medline.com/strategies/skin-health/comprehensive-skin-assessments-correctly-get-whole-picture/" } ] }, { "says": "Frame the chaperone as support for dignity, privacy, explanation, and patient comfort. Do not write it like an accusation against the patient or staff.", "sources": [ { "name": "Integris Group", "url": "https://www.integrisgrp.com/chaperones-in-the-medical-office-setting" }, { "name": "JOGNN", "url": "https://www.jognn.org/article/S0884-2175(21" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "forensic-assault-note", "title": "When Your Assessment May Become Evidence", "search_title": "", "question": "What should I chart when caring for a patient after an alleged assault so the quotes, injuries, behavior, and evidence handling stay objective?", "asked_as": "site:allnurses.com charting alleged assault patient quote injury description evidence", "cluster": "others", "url": "https://shiftiswild.com/notes/forensic-assault-note/", "markdown_url": "https://shiftiswild.com/notes/forensic-assault-note.md", "summary": "A patient comes in after a reported assault. Your note may end up in front of a SANE nurse, provider, investigator, licensing reviewer, attorney, or court. So chart the things that hold up: what you saw, heard, did, collected, and transferred.", "key_points": [ "Use the patient’s exact words when they matter. Mark them as the patient’s words.", "Describe injuries the way you describe any wound: location, size, color, shape, tenderness, drainage, photos/body map if used.", "Describe behavior you can see or hear. Skip your opinion about it.", "For clothing, swabs, kits, or other evidence, chart the item, container, label, seal, time, storage location, and person receiving it.", "Don’t use legal labels unless the patient used that word and you are clearly recording the patient’s own words." ], "one_thing": "Chart the patient’s exact words. Chart what you saw. Chart the exact path of any evidence.", "what_goes_wrong": "The usual mistake is jumping straight to a conclusion: patient was raped, patient was hysterical, boyfriend was abusive, no evidence of assault, kit done. It feels fast. It also hides the facts anyone would need later.\n\nA better note keeps four things separate:\n\n1. What the patient said.\n2. What you observed.\n3. What you assessed or treated.\n4. What happened to possible evidence.\n\nThat separation matters. Later readers were not in the room. They need to know where the words came from: the patient, your assessment, another staff member, or a lab or exam finding.", "rewrites": [ { "situation": "", "before": "Patient was raped by boyfriend.", "after": "Patient stated exact words: [PATIENT EXACT WORDS]. Patient identified the person involved as [NAME/RELATIONSHIP IF GIVEN]. Patient reports event occurred at [LOCATION] on [DATE] at approximately [TIME]." }, { "situation": "", "before": "Patient hysterical and making accusations.", "after": "Patient crying, hands trembling, respirations 24/min, speech clear, answered questions in short phrases. Patient stated exact words: [PATIENT EXACT WORDS]." }, { "situation": "", "before": "Multiple bruises all over body.", "after": "Skin assessment completed with patient permission. Left upper arm: 3 cm x 2 cm purple oval ecchymosis, tender to light palpation, skin intact. Right cheek: 1 cm superficial linear abrasion with scant dried blood. Body map completed." }, { "situation": "", "before": "No injuries noted.", "after": "No visible injury noted to face, neck, chest, abdomen, back, hands, or external thighs during assessment at [TIME]. Patient declined assessment of [BODY AREA] at this time. Patient reports pain to [LOCATION], rated [NUMBER]/10." }, { "situation": "", "before": "Rape kit done and given to police.", "after": "Sexual assault evidence kit [KIT NUMBER] collected by [NAME/TITLE] from [START TIME] to [END TIME]. Kit sealed at [TIME]. Seal intact. Transferred to [OFFICER NAME/BADGE/AGENCY] at [TIME]. Chain-of-custody form signed by [NAMES]." }, { "situation": "", "before": "Clothes bagged.", "after": "Patient’s [ITEM 1], [ITEM 2], and [ITEM 3] placed in separate [PAPER BAG/OTHER APPROVED CONTAINER] per policy at [TIME] by [NAME/TITLE]. Each container labeled with patient identifiers, date, time, item description, and collector initials. Containers sealed and stored in [LOCATION] or transferred to [NAME/TITLE] at [TIME]." }, { "situation": "", "before": "Patient drunk and unreliable.", "after": "Patient smelled of alcohol. Speech slurred. Gait unsteady; required one-person assist from stretcher to bathroom. Patient stated exact words about substance use: [PATIENT EXACT WORDS]. Test result available: [RESULT/TIME] or no test result available at time of note." }, { "situation": "", "before": "Visitor threatening and aggressive.", "after": "Person identified by patient as [RELATIONSHIP] stood between patient and door, raised voice, pointed index finger toward patient, and stated exact words: [EXACT WORDS IF HEARD]. Security notified at [TIME]. Patient moved to [LOCATION] for private assessment." }, { "situation": "", "before": "Patient uncooperative with exam.", "after": "Patient declined photographs and declined removal of clothing at this time. Patient accepted vital signs, pain assessment, and wound care. Patient informed that exam may be paused or stopped at any time." } ], "words_to_avoid": [ { "wording": "victim", "why": "It is a legal or advocacy label, not an assessment finding.", "instead": "patient" }, { "wording": "perpetrator", "why": "It names a legal role you may not be able to determine.", "instead": "person identified by patient as [RELATIONSHIP/NAME]" }, { "wording": "alleged victim", "why": "It can sound like disbelief and adds no clinical detail.", "instead": "patient reports [EVENT]" }, { "wording": "raped", "why": "Use only if recording the patient’s exact word or a documented diagnosis by the appropriate clinician.", "instead": "patient stated exact words: [PATIENT EXACT WORDS]" }, { "wording": "assaulted", "why": "Same problem as above unless it is the patient’s word or a report category required by your facility.", "instead": "patient reports being [HIT/GRABBED/TOUCHED/HELD DOWN/etc.]" }, { "wording": "hysterical", "why": "It is judgmental and vague.", "instead": "crying, trembling, pacing, speaking rapidly, unable to sit still" }, { "wording": "combative", "why": "It does not say what happened.", "instead": "pulled arm away, pushed call bell onto floor, kicked toward staff, declined exam" }, { "wording": "intoxicated", "why": "It may be a conclusion unless backed by findings or test results.", "instead": "odor of alcohol, slurred speech, unsteady gait, test result [RESULT]" }, { "wording": "no evidence of assault", "why": "That is too broad and sounds like a legal conclusion.", "instead": "no visible injury noted to [BODY AREAS ASSESSED] at [TIME]" }, { "wording": "kit done", "why": "It skips who collected it, when, and what happened to it.", "instead": "kit [NUMBER] collected by [NAME/TITLE], sealed at [TIME], transferred to [NAME/TITLE/BADGE] at [TIME]" } ], "cases": [ { "case": "State v. Toomes", "url": "https://www.courtlistener.com/opinion/1055118/state-of-tennessee-v-darrell-toomes/", "court": "Court of Criminal Appeals of Tennessee", "year": "2005", "quote": "", "what_it_shows": "The court affirmed an aggravated rape conviction, and the opinion discussed medical records, nursing notes, lab work, the rape kit, and evidence transfer. “Ms. Bullard testified that she was trained to document all of her lab work and activities to establish an accurate chain of custody.”" }, { "case": "State v. Robinson", "url": "https://www.courtlistener.com/opinion/2701056/state-v-robinson/", "court": "Ohio Court of Appeals", "year": "2012", "quote": "", "what_it_shows": "The court affirmed the convictions and sent the sentencing issue back for resentencing. The opinion discussed the hospital exam, patient statements, intoxication, swabs, and physical findings. “A nurse gave her a sexual assault exam during which the nurse took a swab of her vagina.”" }, { "case": "Neighbors Rehab. Ctr., LLC v. U.S. Dep't of Health & Human Servs.", "url": "https://www.courtlistener.com/opinion/8443798/neighbors-rehab-ctr-llc-v-us-dept-of-health-human-servs/", "court": "Court of Appeals for the Seventh Circuit", "year": "2018", "quote": "", "what_it_shows": "The court affirmed the agency citation and penalty involving a skilled nursing facility’s response to sexual interactions among cognitively impaired residents. “Neighbors' staff documented the interaction in the residents' nursing notes but did not investigate further.”" } ], "guidance": [ { "says": "When the patient’s exact words matter clinically, write them as direct speech. Don’t clean up profanity. Don’t turn the wording into your own legal conclusion.", "sources": [ { "name": "LibreTexts", "url": "https://med.libretexts.org/Bookshelves/Nursing/Clinical_Nursing_Skills_(OpenStax" }, { "name": "RN.org", "url": "https://www.rn.org/courses/coursematerial-173.pdf" } ] }, { "says": "Describe injuries by location, number, type, and characteristics. Use a body map or injury location tool when you have one.", "sources": [ { "name": "LWW Nursing Critical Care", "url": "https://journals.lww.com/nursingcriticalcare/fulltext/2011/07000/10_tips_for_documenting_domestic_violence.11.aspx" }, { "name": "My American Nurse", "url": "https://www.myamericannurse.com/avoiding-bias-and-misinterpretation-in-nursing-documentation/" } ] }, { "says": "Chart what you can observe: appearance, behavior, demeanor, exam findings, statements, and nonverbal behavior.", "sources": [ { "name": "BUMC", "url": "https://www.bumc.bu.edu/gimcovid/files/2021/01/Abuse-Documentation-Guide-2020.pdf" }, { "name": "RegisteredNursing.org", "url": "https://www.registerednursing.org/articles/what-should-nurse-do-suspect-patient-victim-abuse/" } ] }, { "says": "If photographs are taken under facility policy, give enough context to identify the patient, show where the injury is on the body, show the injury close up, and show size reference.", "sources": [ { "name": "My American Nurse", "url": "https://www.myamericannurse.com/avoiding-bias-and-misinterpretation-in-nursing-documentation/" }, { "name": "RN.org", "url": "https://www.rn.org/courses/coursematerial-173.pdf" } ] }, { "says": "Keep legal labels out of the clinical note when plain clinical wording works. Tie subjective information to the speaker. Tie objective information to what you observed.", "sources": [ { "name": "LibreTexts", "url": "https://med.libretexts.org/Bookshelves/Nursing/Clinical_Nursing_Skills_(OpenStax" }, { "name": "ForensicSpot", "url": "https://forensicspot.com/topics/forensic-nursing/forensic-nursing-documentation-standards" } ] } ], "ready_to_copy": "[DATE] [TIME] Patient seen in [LOCATION] after patient-reported assault. Patient identity verified using [IDENTIFIERS]. Patient offered private setting for assessment; patient [ACCEPTED/DECLINED]. Person accompanying patient: [NAME/RELATIONSHIP/NONE]. Person identified by patient as involved in event: [NAME/RELATIONSHIP/UNKNOWN/NOT DISCLOSED].\n\nPatient stated exact words: [PATIENT EXACT WORDS].\n\nPatient reports event occurred at [LOCATION] on [DATE] at approximately [TIME]. Patient reports [WHAT HAPPENED IN PATIENT TERMS]. Patient reports pain to [LOCATION], rated [NUMBER]/10. Patient reports [LOSS OF CONSCIOUSNESS/STRANGULATION/WEAPON USE/SEXUAL CONTACT/BLEEDING/NAUSEA/OTHER] as [DETAILS OR DENIES OR DOES NOT KNOW].\n\nObserved behavior at [TIME]: [CRYING/CALM/TREMBLING/PACING/QUIET/ANSWERING QUESTIONS/OTHER OBSERVABLE FACTS]. Speech [CLEAR/SLURRED/SOFT/LOUD]. Gait [STEADY/UNSTEADY/NOT ASSESSED]. Clothing condition observed: [DESCRIPTION]. No opinion documented beyond observed facts.\n\nVital signs at [TIME]: BP [BP], HR [HR], RR [RR], SpO2 [SPO2], Temp [TEMP]. Neuro status [FINDINGS IF ASSESSED]. Pain reassessed at [TIME]: [RESULT].\n\nInjury assessment completed with patient permission. Findings:\n1. [BODY LOCATION]: [SIZE], [COLOR], [SHAPE], [TYPE OF INJURY], [TENDERNESS], [DRAINAGE/BLEEDING], [SKIN INTACT/OPEN].\n2. [BODY LOCATION]: [SIZE], [COLOR], [SHAPE], [TYPE OF INJURY], [TENDERNESS], [DRAINAGE/BLEEDING], [SKIN INTACT/OPEN].\nNo visible injury noted to [BODY AREAS ASSESSED]. Assessment limited by [PATIENT DECLINED AREA/CLOTHING/PAIN/OTHER]. Body map [COMPLETED/NOT COMPLETED/NOT AVAILABLE]. Photographs [TAKEN/DECLINED/NOT INDICATED] per facility policy; consent [OBTAINED/DECLINED]; photo identifiers [DETAILS].\n\nPotential evidence items identified: [ITEMS]. Items handled per facility policy. [ITEM] placed in [CONTAINER TYPE] by [NAME/TITLE] at [TIME], labeled with [LABEL DETAILS], sealed at [TIME], and [STORED IN LOCATION/TRANSFERRED TO NAME TITLE BADGE AGENCY] at [TIME]. Chain-of-custody form [COMPLETED/NOT APPLICABLE].\n\nProvider [NAME/TITLE] notified at [TIME]. SANE or forensic nurse [NAME/TITLE] notified at [TIME] or [NOT AVAILABLE]. Patient offered [ADVOCATE/SOCIAL WORK/SECURITY/LAW ENFORCEMENT CONTACT/OTHER] per policy; patient [ACCEPTED/DECLINED]. Care provided: [WOUND CARE/MEDICATIONS/LABS/IMAGING/PROPHYLAXIS/SAFETY MEASURES]. Patient response: [RESPONSE]. Patient left in [LOCATION] with [CALL LIGHT/SAFETY PLAN/STAFF MONITORING/OTHER].", "samples_are_written": true }, { "slug": "coworker-impaired", "title": "When a Coworker Seems Unsafe During the Shift", "search_title": "", "question": "What should I write if a nurse, aide, or other staff member appears unsafe, impaired, or not like themselves during the shift?", "asked_as": "nurse coworker seems impaired what to document notify supervisor objective signs", "cluster": "others", "url": "https://shiftiswild.com/notes/coworker-impaired/", "markdown_url": "https://shiftiswild.com/notes/coworker-impaired.md", "summary": "If someone on shift looks unsafe, you are not there to diagnose them. You are there to protect the patient, get the right person involved, and write a clean record of what happened.", "key_points": [ "Protect the patient first. Pause the task, get help, and tell the charge nurse, supervisor, or manager right away.", "Do not write drunk, high, impaired, crazy, or addict unless your facility process has already made that call. Write what you saw, heard, and did.", "In the patient chart, stick to patient care: what happened to the patient, your assessment, what you did, who you notified, and the outcome.", "In the safety report or message to leadership, write the staff-related facts: time, place, behavior you observed, task affected, witnesses, who you told, and what happened next.", "Keep it need-to-know. Do not gossip, guess, or start your own investigation." ], "one_thing": "Write the behavior, the patient impact, and who you notified. Not your diagnosis of the coworker.", "what_goes_wrong": "The usual mistake is turning the note into a label instead of a record.\n\nExample: Nurse was high and unsafe all night.\n\nThat may feel clear when you write it. It is not clear later. What did you actually see? Slurred words? Falling asleep? Med errors? Staggering during a transfer? Patients left alone? Refusing to hand off keys or medications?\n\nThe label skips the facts people can use.\n\nThe other mistake is dumping the whole coworker issue into the patient chart. Do not do that. The chart should explain the patient care issue. Use the safety report, supervisor notification, or internal reporting system for the staff behavior that raised the concern.", "rewrites": [ { "situation": "", "before": "1915 CNA Jane high, almost dropped pt. Charge aware.", "after": "1915 During transfer from bed to chair, assigned CNA staggered backward and released gait belt. This RN held gait belt and assisted patient back to edge of bed. Patient denied pain or dizziness; skin intact; no fall. Charge RN M. King notified at 1917 and came to room. Transfer completed with 2 staff at 1925." }, { "situation": "", "before": "RN A.B. drunk at work. Took her cart.", "after": "2035 Med room. RN A.B. had slurred speech, unsteady gait when walking from Pyxis to medication cart, alcohol-like odor on breath, and dropped two sealed medication cups while preparing 2100 medications for rooms 412 to 416. This RN asked A.B. to pause medication preparation and notified charge RN L. Thomas at 2037. Charge RN assumed medication cart at 2040. No patient injury known at time of report." }, { "situation": "", "before": "Night nurse forgot all meds because she was out of it.", "after": "2135 On MAR review, 2100 metoprolol showed not administered. BP 148/82, HR 78. Order and parameters verified. Metoprolol administered at 2138. Charge RN notified at 2140. Patient resting in bed, no distress noted." }, { "situation": "", "before": "PCA is lazy and unsafe. I refuse to work with her.", "after": "0245 Hall B. PCA C.D. was asleep in chair at nurses station during assigned 0200 rounds. Call light for room 218 active on board at 0246. This RN answered call light at 0247; patient requested toileting. Patient assisted to bathroom with walker and gait belt; no fall or injury observed. Charge RN notified at 0255 and reassigned rounding coverage." }, { "situation": "", "before": "RN is having a breakdown and should not have patients.", "after": "1748 Nurses station. RN E.F. was crying, hands shaking, and stated they could not think clearly enough to take the assignment. E.F. was holding unopened insulin pen and MAR for patient 306. This RN asked E.F. to set insulin pen on counter and notified charge RN at 1750. Charge RN reassigned insulin administration. BG 286 at 1752; insulin administered by charge RN at 1800 per MAR." }, { "situation": "", "before": "I think she is stealing narcs.", "after": "2310 Controlled substance count for drawer 2 was incorrect by one tablet of oxycodone 5 mg during shift count with RN P.L. Medication record and waste log reviewed by this RN and RN P.L.; discrepancy not resolved at time of count. Charge RN and pharmacy notified at 2318 per policy." } ], "words_to_avoid": [ { "wording": "drunk", "why": "You are naming a cause.", "instead": "alcohol-like odor on breath, slurred speech, unsteady gait, red eyes" }, { "wording": "high", "why": "You are guessing without testing or evaluation.", "instead": "nodding off, delayed responses, unable to complete task, repeated confusion about assignment" }, { "wording": "impaired", "why": "It may be a conclusion unless your facility process has made that finding.", "instead": "concern for fitness for duty based on observed behaviors" }, { "wording": "addict", "why": "It labels the person and does not help patient safety reporting.", "instead": "observed behavior or documented discrepancy" }, { "wording": "crazy, psycho, unstable", "why": "It is vague and judgmental.", "instead": "crying, shaking hands, unable to complete handoff, stated unable to continue assignment" }, { "wording": "lazy, useless", "why": "It attacks character instead of describing the work.", "instead": "assigned rounds not completed, call light not answered, task not performed by scheduled time" }, { "wording": "almost killed the patient", "why": "It is dramatic and nonspecific.", "instead": "exact event, patient assessment, intervention, and outcome" }, { "wording": "stealing narcs", "why": "It accuses intent.", "instead": "controlled substance discrepancy noted; count incorrect by [NUMBER]; pharmacy and charge RN notified" }, { "wording": "not like herself", "why": "It is too vague by itself.", "instead": "specific change from observed baseline, such as confusion, repeated questions, disorganized handoff, or difficulty following directions" } ], "cases": [], "guidance": [ { "says": "Chart what you observed, with times. Do not guess the reason. Include what you saw, where it happened, when it happened, and what care was affected.", "sources": [ { "name": "CEUfast", "url": "https://ceufast.com/course/recognizing-impairment-in-the-workplace" }, { "name": "NCBI Bookshelf", "url": "https://www.ncbi.nlm.nih.gov/books/NBK599391/" } ] }, { "says": "Report unsafe practice or a possible fitness-for-duty concern through the right clinical chain. The goal is to protect patients and let the facility process handle the concern.", "sources": [ { "name": "ANA", "url": "https://codeofethics.ana.org/provision-3-5" }, { "name": "Nursing CE Central", "url": "https://nursingcecentral.com/lessons/recognition-and-reporting-of-impaired-care/" } ] }, { "says": "If patient safety or a patient condition is involved, keep your communication structured: what you noticed, what changed, what you did, and who needs to act next.", "sources": [ { "name": "AHRQ", "url": "https://www.ahrq.gov/patient-safety/settings/long-term-care/resource/facilities/ltc/mod1sess2.html" }, { "name": "NCBI Bookshelf", "url": "https://www.ncbi.nlm.nih.gov/books/NBK599391/" } ] }, { "says": "Keep the circle small. Treat a possible health, fatigue, or substance-related concern as need-to-know patient safety information, not a unit conversation.", "sources": [ { "name": "ANA", "url": "https://codeofethics.ana.org/provision-3-5" }, { "name": "Washington Nursing Commission", "url": "https://nursing.wa.gov/sites/default/files/2022-06/600006.pdf" } ] }, { "says": "Make the record easy to rebuild later: date, time, place, people involved, observed facts, patient impact, and notifications.", "sources": [ { "name": "NCBI Bookshelf", "url": "https://www.ncbi.nlm.nih.gov/books/NBK610473/" }, { "name": "CEUfast", "url": "https://ceufast.com/course/recognizing-impairment-in-the-workplace" } ] } ], "ready_to_copy": "[DATE] [TIME]: During [CARE/TASK], patient safety concern occurred when [OBJECTIVE EVENT AFFECTING PATIENT CARE]. Patient assessed: [ASSESSMENT FINDINGS]. Interventions: [WHAT YOU DID FOR THE PATIENT]. [CHARGE RN/SUPERVISOR NAME AND TITLE] notified at [TIME]. [PROVIDER NAME/TITLE] notified at [TIME] if clinically indicated. Patient response/outcome: [RESPONSE/OUTCOME]. Plan: [MONITORING/FOLLOW-UP].", "samples_are_written": true }, { "slug": "bias-refusal", "title": "When Bias Changes Who Gives Care", "search_title": "", "question": "What do I chart when a patient or family member refuses a caregiver because of race, religion, gender, accent, or another protected trait?", "asked_as": "patient refuses nurse because of race what to chart", "cluster": "others", "url": "https://shiftiswild.com/notes/bias-refusal/", "markdown_url": "https://shiftiswild.com/notes/bias-refusal.md", "summary": "A patient or family member may refuse a caregiver because of race, religion, gender, accent, or something else about that person. Don’t argue it in the note. Don’t shame them. Don’t diagnose bias.\nChart what happened. What was said. What care was due. What you did. Who you told. And whether care got delayed or refused.", "key_points": [ "Chart the behavior and the reason they gave. Not your opinion of them.", "If the reason was a protected trait, don’t bury it as a normal preference.", "Name the care on the line: medication, assessment, toileting, wound care, discharge teaching, safety check, whatever it was.", "If care was delayed, refused, or reassigned, notify the charge nurse or supervisor and chart that you did.", "Use an incident report or your internal process for staff-directed discrimination, threats, or safety concerns." ], "one_thing": "Chart the conduct, the care at stake, the escalation, and the outcome. Not your opinion of the patient.", "what_goes_wrong": "The usual mistake is too simple: patient wanted a different nurse, assignment changed.\n\nThat leaves out the part that matters. The change was not about skill, availability, pain, privacy, or trouble understanding instructions. It was about who the caregiver was.\n\nIf the chart only says the patient requested another nurse, it can read like the first nurse did something wrong. Or like care got delayed for no clear reason.\n\nYou don’t have to solve the whole policy issue in the chart. That is not the job. Your job is to make the clinical record clear: who refused, what they refused, why they said they refused it, what care was due, what you explained, who you notified, and what happened next.", "rewrites": [ { "situation": "", "before": "Pt racist and refused RN. Reassigned.", "after": "0735 Pt alert and oriented x4. Pt stated he did not want RN [NAME] to administer 0800 vancomycin because of RN’s race. Explained medication due time and that delay may affect antibiotic schedule. Pt declined medication from assigned RN at this time. Charge RN [NAME] notified at 0738. Vancomycin administered at 0815 by RN [NAME] per charge RN direction. No adverse reaction noted." }, { "situation": "", "before": "Family does not want male CNA. Female CNA sent.", "after": "0940 Spouse requested female staff for perineal care due religious modesty. Pt awake, alert, and able to answer questions. Pt confirmed request and agreed to wait for female staff if available. Charge RN [NAME] notified. Female CNA available; perineal care completed at 0955. No delay to scheduled medications or treatments." }, { "situation": "", "before": "Daughter refused Black nurse.", "after": "1505 Daughter [NAME] stated she did not want assigned RN [NAME] in room because RN is Black. Pt alert and oriented x3. Pt stated he accepts care from assigned RN. Daughter informed that care decisions are directed by pt. Charge RN [NAME] notified. Wound dressing changed by assigned RN at 1520. Pt tolerated well." }, { "situation": "", "before": "Pt does not like nurse’s accent. Changed nurse.", "after": "1130 Pt stated she was having difficulty understanding discharge teaching from RN [NAME]. RN repeated instructions slowly, provided written discharge instructions, and used teach-back. Pt correctly stated medication schedule. Pt then stated she did not want care from staff with [PATIENT’S WORDS ABOUT ACCENT OR ORIGIN]. Charge RN [NAME] notified. Discharge teaching completed at 1155 with RN [NAME] present." }, { "situation": "", "before": "Family aggressive. Nurse removed.", "after": "1830 Son [NAME] raised voice toward assigned RN [NAME] and stated: [EXACT WORDS USED]. Son stood in doorway and RN was unable to leave room without assistance. RN exited when safe. Charge RN [NAME] and security notified at 1832. Pt assessed by charge RN at 1838. VS [VITAL SIGNS]. Scheduled insulin due at 1900; plan reviewed with charge RN." } ], "words_to_avoid": [ { "wording": "racist, sexist, bigoted", "why": "It is a conclusion and may hide the actual behavior.", "instead": "[NAME/RELATIONSHIP] stated: [EXACT WORDS USED]." }, { "wording": "preference", "why": "It can make a protected-trait refusal sound like a routine comfort request.", "instead": "Pt refused care from assigned [ROLE] because of [STATED REASON]." }, { "wording": "fired the nurse", "why": "Patients do not fire staff. It sounds informal and unclear.", "instead": "Pt declined care from assigned RN after explanation of needed care." }, { "wording": "noncompliant", "why": "Too broad. It does not say what care was refused.", "instead": "Pt refused [SPECIFIC CARE] after risks/benefits explained." }, { "wording": "foreign nurse", "why": "Labels the caregiver instead of documenting the patient’s words or the communication issue.", "instead": "Pt stated difficulty understanding discharge teaching; written instructions and teach-back used." }, { "wording": "accommodated", "why": "Does not show who made the decision or why.", "instead": "Charge RN notified; assignment reviewed per unit process." }, { "wording": "felt unsafe", "why": "A conclusion without facts.", "instead": "Pt/family [BEHAVIOR], stated [WORDS], blocked [LOCATION], threatened [ACTION]." }, { "wording": "no issue", "why": "Can erase a real event.", "instead": "Care completed without delay after charge RN review." } ], "cases": [ { "case": "Spragg v. Shore Care", "url": "https://www.courtlistener.com/opinion/1997989/spragg-v-shore-care/", "court": "New Jersey Superior Court, Appellate Division", "year": "1996", "quote": "", "what_it_shows": "This case involved a male certified home health aide who challenged a home health employer’s gender-based assignment practice tied to female patients refusing male aides. The charting point is simple: when an assignment changes because a patient or family objects to the caregiver, the facts in the record matter." } ], "guidance": [ { "says": "If the refusal is based on race, ethnicity, religion, gender, disability, or a similar trait, don’t treat it like a routine staffing request. Bring in the chain of command instead of making the call alone at the bedside.", "sources": [ { "name": "PubMed", "url": "https://pubmed.ncbi.nlm.nih.gov/17167369/" }, { "name": "BMA", "url": "https://www.bma.org.uk/media/5144/bma-guidance-on-how-to-deal-with-discrimination-from-patients-march-2022.pdf" } ] }, { "says": "Be careful about repeatedly granting demands about caregiver traits. The response can affect the caregiver’s work environment and patient care.", "sources": [ { "name": "Clinician.com", "url": "https://www.clinician.com/articles/146579-ethical-responses-if-patients-ask-for-provider-of-different-race" }, { "name": "BMA", "url": "https://www.bma.org.uk/media/5144/bma-guidance-on-how-to-deal-with-discrimination-from-patients-march-2022.pdf" } ] }, { "says": "For any refusal, chart the care offered, what you explained, the patient’s response, who you notified, and the outcome. Keep the language neutral.", "sources": [ { "name": "American Nurse", "url": "https://www.myamericannurse.com/patient-refusal-when-a-patient-refuses-a-nurse-assignment/" }, { "name": "Intuites", "url": "https://intuites.healthcare/blog/charting-patient-refusals-rn-documentation-playbook-2026.html" } ] } ], "ready_to_copy": "[DATE] [TIME] Pt [ALERT/ORIENTED STATUS OR RELEVANT ASSESSMENT]. [PATIENT/FAMILY MEMBER NAME AND RELATIONSHIP] stated: [PATIENT OR FAMILY MEMBER'S EXACT WORDS]. Assigned caregiver [NAME/ROLE] was [PRESENT/NOT PRESENT]. Care due at this time: [MEDICATION/ASSESSMENT/TREATMENT/ADL/DISCHARGE TEACHING/OTHER CARE].\n\nPt was addressed directly regarding care decision. Pt stated [ACCEPTS CARE FROM ASSIGNED CAREGIVER / REFUSES CARE FROM ASSIGNED CAREGIVER / WANTS TO WAIT FOR SUPERVISOR REVIEW]. Explained [CARE NEEDED], expected timing [TIME], and possible effect of delay [DELAY/RISK]. Pt verbalized understanding by [METHOD].\n\nCharge RN/supervisor [NAME] notified at [TIME]. Provider [NAME] notified at [TIME] due to [CARE DELAYED/CARE REFUSED/CLINICAL CONCERN], if applicable. Outcome: [CARE COMPLETED BY ASSIGNED CAREGIVER / CARE COMPLETED BY ALTERNATE STAFF PER SUPERVISOR DIRECTION / CARE NOT COMPLETED DUE TO PT REFUSAL]. Pt condition after event: [ASSESSMENT]. Call light within reach. Safety measures in place: [MEASURES].", "samples_are_written": true }, { "slug": "fix-it-now", "title": "You already signed it and it is wrong", "search_title": "How to correct a nursing note you already signed", "question": "How do you correct a note you already signed without it looking like a cover-up?", "asked_as": "charted wrong already signed how to correct addendum amend note nursing", "cluster": "cover", "url": "https://shiftiswild.com/notes/fix-it-now/", "markdown_url": "https://shiftiswild.com/notes/fix-it-now.md", "summary": "You signed the note. Then you caught the wrong side, the wrong time, or a detail you left out. Now make the correction easy to trace and the accurate information easy to find. Keep the time you correct the note separate from the time you gave the care.", "key_points": [ "Check whether the mistake could affect care now. If it could, notify the appropriate clinician and address the patient’s needs. The wording can wait.", "Say what you’re doing: correcting a wrong fact, adding information, or documenting earlier care you left out.", "Use your facility’s approved process for correcting a signed note. It should keep the original record and show who made the amendment and when.", "Identify the original note, what was wrong, what’s accurate, and why you’re making the change. Keep the event time separate from the current entry time.", "Check the other affected parts of the chart and communicate the correction. Fixing the narrative may not fix the medication record, flowsheet, or handoff." ], "one_thing": "Make the correction easy to trace, not the mistake hard to find.", "what_goes_wrong": "A common mistake is announcing that you changed something without saying what changed. If you write only that documentation was updated, the next nurse has to compare two versions and guess which fact to use.\n\nYou have two things to explain: **what happened to the patient** and **what you’re changing in the record**. Cover both.\n\nA new assessment also cannot establish an old finding. Seeing the IV in the right arm now does not, by itself, prove where it was yesterday. An order for a medication does not prove you gave it.\n\nYou’re not trying to make the note look untouched. You’re making the sequence clear.", "rewrites": [ { "situation": "", "before": "Correction", "after": "Identifies a wrong statement and gives the accurate information without removing the record’s history." }, { "situation": "", "before": "Addendum", "after": "Adds information or clarification to a completed note, such as information you received after signing." }, { "situation": "", "before": "Late entry", "after": "Documents an earlier observation or action you did not record at the time. It identifies both the earlier event time and the current entry time." }, { "situation": "", "before": "Instead of this", "after": "Write something like this" }, { "situation": "Laterality correction", "before": "09/12/2026 0940: Previous IV note corrected.", "after": "09/12/2026 0940 — Correction to nursing note signed 09/12/2026 at 0910: The peripheral IV I inserted at 0900 was in the right forearm, not the left forearm. Left forearm was entered incorrectly in the original note. Correction is based on my recollection of performing the insertion. A. Lee, RN." }, { "situation": "Incorrect oxygen documentation", "before": "09/12/2026 1120: Oxygen documentation clarified. Patient stable.", "after": "09/12/2026 1120 — Correction to nursing note signed 09/12/2026 at 1050: At the 1045 assessment, SpO₂ was 97% while the patient was receiving oxygen at 2 L/min by nasal cannula. The original note incorrectly states room air. I observed the nasal cannula in place and flowmeter at 2 L/min during that assessment. A. Lee, RN." }, { "situation": "Information received after signing", "before": "09/12/2026 1430: Admission history updated.", "after": "09/12/2026 1430 — Addendum to admission note signed 09/12/2026 at 1330: At 1420, the patient’s daughter reported that the patient uses a walker for all ambulation at home. This information was not available when the admission note was signed. Receiving nurse J. Patel, RN, notified at 1425. A. Lee, RN." }, { "situation": "Earlier care omitted from a signed note", "before": "09/12/2026 1800: Patient repositioned at 1600 as usual.", "after": "09/12/2026 1800 — Late entry for care provided 09/12/2026 at 1600, omitted from nursing note signed at 1615: At 1600, I assisted the patient from supine to the left side and placed a pillow between the knees. This entry is based on my recollection of providing that care. A. Lee, RN." } ], "words_to_avoid": [ { "wording": "Correcting information", "why": "Leaves the reader guessing which fact changed.", "instead": "Name the original note, inaccurate statement, and accurate information." }, { "wording": "Charted in error", "why": "Does not make clear whether you mean one detail or the whole note.", "instead": "Specify the affected detail, such as incorrect laterality." }, { "wording": "Patient stable / no harm done", "why": "Does not explain the correction and may claim more than you assessed.", "instead": "Record the actual assessment findings and their time, when relevant." }, { "wording": "As usual", "why": "Describes a routine, not proof that this event happened.", "instead": "State the specific action you remember performing." }, { "wording": "Per manager request", "why": "Says who asked for the entry, not whether the content is accurate.", "instead": "Document the factual basis; address disagreements through the appropriate supervisory process." } ], "cases": [], "guidance": [ { "says": "After signing, use a supplemental entry to correct inaccurate information in the original note.", "sources": [ { "name": "Salem Health", "url": "https://www.salemhealth.org/docs/default-source/common-ground/notes---addendum-workflow-and-documentation-guidelines---tip-sheet.pdf?sfvrsn=914baac4_0" }, { "name": "Grow Therapy", "url": "https://help.growtherapy.com/en/articles/8949845-amend-or-correct-a-signed-note" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "audit-trail", "title": "The chart remembers more than your note", "search_title": "What the EHR audit trail shows about your charting", "question": "What does the EHR record about you besides what you typed?", "asked_as": "EHR audit trail metadata nurse chart access log timestamp discovery", "cluster": "cover", "url": "https://shiftiswild.com/notes/audit-trail/", "markdown_url": "https://shiftiswild.com/notes/audit-trail.md", "summary": "You’ve signed the note. Then you catch the wrong time, or realize you had the wrong patient’s chart open. The EHR may have logged your access, entry, and edits separately from the note you see. Your next step is to make that sequence clear, not make the screen look untouched.", "key_points": [ "Handle any patient-safety problem first. Correcting the chart does not replace a call about something that affects care.", "Separate care time from entry time. If you’re charting later, use the approved late-entry process.", "Use the EHR’s correction workflow. Don’t try to make a signed entry look as if the error never happened.", "If you opened the wrong chart or accessed one unnecessarily, stop and report it through your facility’s process. Don’t reopen the chart to investigate your own access.", "Ask what each timestamp means. Access time, result time, entry time, and signature time tell you different things." ], "one_thing": "Keep the care time, entry time, and correction history clear. Don’t force them to match.", "what_goes_wrong": "It’s easy to treat the note you see as the whole record.\n\nIt may not be. The EHR may keep track of which account opened the chart, which sections were accessed, when information was entered, and what changed. Your routine printout may not show all of that.\n\nYou provide care at 0815 and chart it at 1600. Both times can be right. The problem starts when you make the entry look as though you wrote it at 0815, or give an exact care time you don’t actually remember.\n\nThe question may not be whether you documented an assessment. It may be when you did it, when you charted it, and what you changed afterward.\n\nA clear correction explains why the versions differ. Simply replacing the entry may leave the earlier version or change history in place, with nothing to tell the next reader which information is right. The correction takes another step. It also gives that reader an explanation instead of a discrepancy.", "rewrites": [ { "situation": "", "before": "Entered at 1040, presented without identifying the delay: 0815—Headache 6/10. Acetaminophen given. Pain improved.", "after": "Late entry entered 1040 for care provided at 0815: Patient reported headache 6/10. Acetaminophen 650 mg PO administered per PRN order. At 0915, patient reported headache 2/10." }, { "situation": "", "before": "Signed entry silently replaced: 1500—SpO₂ 98% on room air. Changed to SpO₂ 98% on 2 L oxygen.", "after": "Correction entered 1540 to the 1500 assessment: SpO₂ was 98% on oxygen at 2 L/min via nasal cannula, not room air." }, { "situation": "", "before": "The result’s timestamp is used as the review time: 0832—Potassium 2.9 mmol/L. Labs reviewed. Provider aware.", "after": "1110—Reviewed potassium result of 2.9 mmol/L, resulted at 0832. Dr. Chen notified by telephone at 1113; order received for potassium replacement." }, { "situation": "", "before": "An exact time is supplied from uncertain memory: 1000—Patient ambulated 50 feet with walker.", "after": "Late entry entered 1340: Patient ambulated approximately 50 feet with walker and one-person assistance after breakfast. Exact time of ambulation not recalled. No dizziness reported during ambulation." } ], "words_to_avoid": [ { "wording": "Provider aware", "why": "Does not identify who was contacted, when, or how.", "instead": "Provider’s name, contact time, method, and response." }, { "wording": "All records reviewed", "why": "Claims a broader review than you may have performed.", "instead": "Identify the relevant result, report, or record and when you reviewed it." }, { "wording": "0800, when the time is guessed", "why": "Turns uncertain memory into apparent precision.", "instead": "An explicitly approximate time with a reliable basis, or state that the exact time is not recalled." }, { "wording": "Chart fixed", "why": "Does not explain what was wrong or which information is accurate.", "instead": "Identify the affected entry, the correction, and the current correction time." } ], "cases": [ { "case": "Wiese v. Riverton Memorial Hospital, LLC", "url": "https://www.courtlistener.com/opinion/9289181/rebecca-a-wiese-and-tyler-d-wiese-individually-and-as-the-natural/", "court": "Wyoming Supreme Court", "year": "2022", "quote": "", "what_it_shows": "The printed records showed nursing entries about events from 8:15–8:20 a.m., but those entries were created between 4:06 and 4:08 p.m. The family asked for the associated audit trail. The court ruled that audit trails qualified as health care information under Wyoming’s since-repealed hospital-records law. It sent the case back for further proceedings because factual questions about compliance remained. That was not a finding that the nurses fabricated care. It also does not establish a nationwide right to every audit log." }, { "case": "Hutchinson, B. v. Verstraeten, T.", "url": "https://www.courtlistener.com/opinion/10317273/hutchinson-b-v-verstraeten-t/", "court": "Superior Court of Pennsylvania", "year": "2023", "quote": "", "what_it_shows": "The patients alleged that records had been altered and obtained an order for a complete, unredacted audit trail. The trial court, however, excluded testimony from their proposed health-information-technology expert. The appellate court affirmed the defense judgment because the appeal did not establish an abuse of discretion. Audit information was requested and disputed. That did not turn the alteration allegations into established facts." }, { "case": "Estate of Eden v. Goldstein", "url": "https://www.courtlistener.com/opinion/10292281/estate-of-eden-v-goldstein/", "court": "Ohio Court of Appeals", "year": "2024", "quote": "", "what_it_shows": "The trial court ordered a virtual inspection of the patient’s electronic records, subject to protective arrangements. At a compliance hearing, the defendants produced portions of unredacted audit trails and access logs. The appellate court dismissed the appeal for lack of jurisdiction. It did not decide whether malpractice or record alteration had occurred. The records inquiry went beyond the printed note and into the underlying electronic system." } ], "guidance": [ { "says": "Keep your notes up to date so the next clinician has current information to work with.", "sources": [ { "name": "Berxi", "url": "https://www.berxi.com/resources/articles/nurses-notes/" }, { "name": "CareerStaff", "url": "https://www.careerstaff.com/clinician-life-blog/nursing/charting-in-nursing-dos-and-donts/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "not-sure", "title": "Chart what you know and name what you do not", "search_title": "How to chart something you are not sure about", "question": "What do you write when you do not know what you are looking at?", "asked_as": "not sure what to chart uncertain assessment nursing how to word", "cluster": "cover", "url": "https://shiftiswild.com/notes/not-sure/", "markdown_url": "https://shiftiswild.com/notes/not-sure.md", "summary": "You signed a note that sounds more certain than you were. Or you left out a finding because you could not identify it. Check the patient first. Then make the record match what you observed, what you still do not know, and what you did next. You do not need a diagnosis to write a useful nursing note.", "key_points": [ "Check the patient now. If the finding could signal an urgent problem, get help before you work on the note.", "Separate observation from interpretation. Write what you saw, measured, heard, or assessed. If you suspect an explanation, say it is suspected.", "Name the specific unknown. Not knowing the cause is different from not knowing the baseline. Neither is the same as an assessment you could not finish.", "Correct an existing entry openly. Use the approved correction or late-entry process. Preserve the original, and keep the entry time separate from the event time.", "Document the follow-through. Record whom you contacted, what concern you reported, the response, and your reassessment. An intention to monitor is not enough." ], "one_thing": "Be exact about what you observed, honest about what you do not know, and clear about what you did next.", "what_goes_wrong": "When you're new, describing an unfamiliar finding can feel like it isn't enough. So you reach for a diagnosis. With more experience, you may recognize a pattern and chart the explanation before checking whether it fits this patient. Either way, a reasonable suspicion can land in the record as an unsupported fact.\n\nLeaving the finding out does not solve that. The next clinician cannot tell whether you found nothing unusual, never assessed the area, or saw something you could not identify.\n\nYou do not need to hedge every sentence. Be clear about what you observed and where that observation stops. You may know the area is red and warm. You may not know why.\n\nAnd you do not have to wait for a diagnosis to act. If a change concerns you, escalate it.", "rewrites": [ { "situation": "", "before": "Left calf cellulitis.", "after": "1400: Left calf with approximately 4 × 3 cm area of redness, warmer than surrounding skin, and tenderness with light palpation. Cause not established. NP Patel notified at 1405 of findings; bedside evaluation requested." }, { "situation": "", "before": "Patient confused as usual.", "after": "1030: Patient states correct name but identifies hospital as home and cannot state month. Baseline orientation not yet verified. Dr. Chen notified at 1035 of findings and unknown baseline; assessment requested." }, { "situation": "", "before": "IV infiltrated. Will continue to monitor.", "after": "1340: Swelling around left forearm peripheral IV site; patient reports burning. Findings concerning for infiltration. Infusion stopped and site managed per facility protocol. Charge RN Lee notified at 1342; bedside assessment requested. 1350: Swelling unchanged; patient reports decreased burning." }, { "situation": "", "before": "Skin intact.", "after": "0900: Sacral skin not visualized; patient declined turning because of pain. Skin condition in that area not assessed. Charge RN Lee notified at 0910; assistance with pain management and positioning requested to complete assessment." }, { "situation": "", "before": "An already-signed entry reads: 0800 No drainage from wound. You observed the dressing but did not see the wound.", "after": "Correction entered 0845 regarding 0800 assessment: No drainage was visible on the outer dressing. Dressing was not removed, and wound drainage beneath it was not assessed." }, { "situation": "", "before": "No entry because you could not identify a heel finding.", "after": "Late entry entered 1630 for observation at approximately 1500: Purple discoloration noted on left heel during sock removal; skin appeared intact. Area was not measured, and cause was not determined at that time. Charge RN Lee notified at 1625 of the earlier finding; reassessment requested." } ], "words_to_avoid": [ { "wording": "Normal / WNL", "why": "Can make a limited or incomplete assessment sound comprehensive.", "instead": "Specific assessed findings; identify any area not assessed." }, { "wording": "Apparently / seems", "why": "Leaves the reader guessing what you actually observed.", "instead": "Observable findings followed by the specific uncertainty." }, { "wording": "As usual / baseline", "why": "Suggests a comparison you may not have verified.", "instead": "Baseline not yet verified, or identify the source and comparison." }, { "wording": "Definitely / obviously", "why": "Adds confidence without adding evidence.", "instead": "Findings supporting the assessment; suspected when appropriate." }, { "wording": "Refused assessment", "why": "May obscure what was offered, what could not be completed, and why.", "instead": "Describe the assessment offered, the patient’s response, and the remaining limitation." }, { "wording": "Will continue to monitor", "why": "Gives no assessment target, timing, or escalation plan.", "instead": "State what will be reassessed and when, consistent with the clinical situation and orders; document the result separately." } ], "cases": [ { "case": "Manter v. CPF Senior Living – Northgate Park L.L.C.", "url": "https://www.courtlistener.com/opinion/9492977/manter-v-cpf-senior-living-northgate-park-llc/", "court": "Ohio Court of Appeals", "year": "2024", "quote": "", "what_it_shows": "The opinion describes an unexplained gap in nursing notes and missing bathing documentation. Staff also described stand-by bathing assistance differently. The appellate court reversed part of the judgment, including the ruling on the contract claim. Factual disputes remained about the care needed and received. That does not mean the court found that missing notes caused the resident’s injury. The practical point is narrower: when the record does not say what assistance actually happened, it leaves uncertainty about the care." }, { "case": "MIKE SCOTTMAN v. EMORY HEALTHCARE, INC.", "url": "https://www.courtlistener.com/opinion/10606290/mike-scottman-v-emory-healthcare-inc/", "court": "Court of Appeals of Georgia", "year": "2025", "quote": "", "what_it_shows": "The opinion describes IV assessments at 0600 and 0700 documenting no redness, swelling, or drainage. Swelling and inflammation were then observed around shift change. The parents initially alleged that hourly observations and notes were missing. The nursing records contradicted that theory. The appellate court affirmed judgment for Emory. Its analysis included defects in the plaintiffs’ expert affidavits. Among them: the medical records underlying the opinions were absent from the court record. The ruling did not establish that a documented normal assessment can never miss a problem. Neither case establishes that a particular correction or addendum would have changed the outcome." } ], "guidance": [ { "says": "Use abbreviations sparingly, and stick to recognizable ones. If another clinician could misunderstand the wording, spell it out.", "sources": [ { "name": "NPrush", "url": "https://nprush.com/nursing-documentation-what-to-write-and-what-to-avoid-writing/" }, { "name": "CareerStaff", "url": "https://www.careerstaff.com/clinician-life-blog/nursing/charting-in-nursing-dos-and-donts/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "order-looks-wrong", "title": "The order looked wrong and the doctor disagreed", "search_title": "What to do when an order looks wrong", "question": "What do you write when you question an order and the doctor does not agree?", "asked_as": "questioned doctor order nurse disagreed how to document refuse to carry out", "cluster": "cover", "url": "https://shiftiswild.com/notes/order-looks-wrong/", "markdown_url": "https://shiftiswild.com/notes/order-looks-wrong.md", "summary": "You questioned the order. The physician disagreed. Now you need to chart what happened. Maybe you already gave the medication; maybe your whole note says *MD aware*. Start with the patient. Then document why you were concerned, how the physician responded, and what happened next.", "key_points": [ "Check the patient first. If the concern is still unresolved, or you've already carried out the order, get the clinical review the situation needs. Urgent care comes before the note.", "Name the order and why you questioned it. Include the findings behind your concern, not just your conclusion that the order looked wrong.", "Document the conversation. Who did you reach? When? What did you tell them, and what was the response?", "Say what you actually did. Was the medication given, not given, or held under a new order? What escalation and reassessment followed?", "Correct omissions openly. Use your facility's correction or late-entry process. Make clear when the event happened and when you entered the note." ], "one_thing": "Chart the concern, the response, and what happened next—not your verdict on the doctor.", "what_goes_wrong": "The common mistake is charting the disagreement and leaving out the care:\n\n*MD notified. Insisted medication be given.*\n\nThat tells me there was friction. It doesn't tell me which medication was involved, what prompted the call, or whether the physician heard the actual pulse and blood pressure rather than a general concern. Was the dose given? Did you ask for further review?\n\nTwo years later, the reader won't have your memory of that call. Those details need to be in the note.\n\nNeutral wording does **not** mean hiding that the physician declined your request. State what you asked for and how the physician responded. Don't guess at motives. *Requested bedside evaluation; Dr. Lee declined the request* describes an exchange. *Dr. Lee did not care* claims to know what someone was thinking.\n\nAnd a well-written note cannot replace action. If the safety concern is still unresolved, you still need a clinical response.", "rewrites": [ { "situation": "", "before": "MD aware of low pulse. Insisted metoprolol be given.", "after": "0905: Before scheduled metoprolol tartrate 25 mg PO, apical pulse 48/min; BP 92/54 mm Hg. Patient denies dizziness. Reported findings to Dr. Lee by telephone and requested review before administration because of bradycardia and low BP. Dr. Lee advised administering the ordered dose; no order change. Dose not administered at this time; further review requested through charge RN." }, { "situation": "", "before": "Doctor refused to listen. Supervisor aware.", "after": "0908: Concern remains about administering metoprolol with pulse 48/min and BP 92/54 mm Hg. Charge RN Patel notified of findings, Dr. Lee’s response, and dose not yet administered. Requested further clinical review. RN Patel contacting covering attending through unit escalation pathway." }, { "situation": "", "before": "Medication held. Patient fine.", "after": "0916: Dr. Lee entered order to hold morning metoprolol dose. Dose not administered; medication administration record updated. 0920: Pulse 50/min; BP 96/56 mm Hg. Patient denies dizziness." }, { "situation": "", "before": "Before", "after": "Better documentation" }, { "situation": "", "before": "Gave antibiotic as ordered. Allergy noticed afterward. MD aware.", "after": "1400: Cefazolin 2 g IV infusion started. 1406: While reviewing outside records, identified documented prior reaction of hives to cefazolin. Infusion stopped at 1406. Patient denies itching or dyspnea; no rash observed. BP 118/72 mm Hg, pulse 82/min, respirations 16/min, SpO₂ 98% on room air. Dr. Chen notified at 1408 of prior reaction and current infusion exposure; bedside evaluation requested. Pharmacy contacted." }, { "situation": "", "before": "Earlier note silently changed to include the call details.", "after": "1100 late entry for 0905 today: During telephone discussion with Dr. Lee, reported pulse 48/min and BP 92/54 mm Hg before scheduled metoprolol and requested dose review. Dr. Lee advised administering the ordered dose. This entry adds discussion details omitted from my earlier note." } ], "words_to_avoid": [ { "wording": "MD aware", "why": "Does not identify the information communicated or response", "instead": "Physician’s name, time, findings reported, response" }, { "wording": "Insisted / refused to listen", "why": "Emphasizes conflict without identifying the decision", "instead": "Requested dose review; physician advised continuing original order" }, { "wording": "Unsafe order", "why": "Gives a conclusion without its clinical basis", "instead": "Concern for additional BP reduction with current BP 92/54 mm Hg" }, { "wording": "Held per MD", "why": "Misstates the source if no hold was ordered", "instead": "Dose not administered pending further review; no hold order received" }, { "wording": "Patient fine", "why": "Does not show what was reassessed", "instead": "Relevant symptoms, examination findings, and measurements" } ], "cases": [ { "case": "Black v. Ohio Bd. of Nursing", "url": "https://www.courtlistener.com/opinion/9355865/black-v-ohio-bd-of-nursing/", "court": ", Ohio Court of Appeals", "year": "2022", "quote": "", "what_it_shows": "The appellate court affirmed a judgment that upheld the nursing board's suspension of a nurse's license for infractions involving the care of two terminally ill patients. The decision describes the board's allegations that medications were given without documentation that the nurse questioned the orders or consulted other team members about their accuracy, validity, or potential harm. Separately, the hearing examiner found that, for Patient I, the nurse had failed to question the order or communicate concerns about potential harm to another team member. Missing documentation is one issue. Failure to communicate is another. Both appear in the decision. See paragraphs 1, 10, and 15. This wasn't simply a case about a poorly chosen phrase in a note. It does not establish that better wording alone would have changed the outcome. Charting that an order existed is not the same as charting how you questioned it, who you consulted, and what you did next." } ], "guidance": [ { "says": "If you question an order's accuracy or meaning, clarify it. Don't guess.", "sources": [ { "name": "North Carolina Board of Nursing", "url": "https://www.ncbon.com/sites/default/files/documents/2024-03/ps-physician-orders-communication-and-implementation.pdf" }, { "name": "AMN Healthcare", "url": "https://www.amnhealthcare.com/blog/nursing/contract/common-nurse-charting-mistakes-to-avoid/" } ] }, { "says": "If you're still unsure about carrying out the order, bring in the appropriate nursing leadership.", "sources": [ { "name": "Kentucky Board of Nursing", "url": "https://kbn.ky.gov/KBN%20Documents/aos14-implementation-of-patient-care-orders.pdf" }, { "name": "RegisteredNursing.org", "url": "https://www.registerednursing.org/articles/does-nurse-always-follow-doctors-orders/" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "chain-of-command", "title": "Going up the ladder so it counts", "search_title": "Nursing chain of command: how to document it", "question": "How do you document an escalation so it actually protects you?", "asked_as": "chain of command nursing escalated charge nurse supervisor document", "cluster": "cover", "url": "https://shiftiswild.com/notes/chain-of-command/", "markdown_url": "https://shiftiswild.com/notes/chain-of-command.md", "summary": "You raised the concern. The chart says *Charge aware*, or says nothing about the conversation at all. If the patient is still at risk, address that first. Then fill the gap through the appropriate late-entry or amendment process. Don't make it look like you charted it earlier.", "key_points": [ "Patient first. If the concern is still active, reassess and escalate now. Don't hold up an emergency response to finish a note or work through every management level.", "Record five things: the time, the person’s name and role, what you communicated, their response, and what you did next.", "Separate an attempt from a conversation. Sending a page isn't the same as getting a callback. A promise to assess isn't a completed assessment.", "Show the follow-through. Chart your reassessment, further contact, bedside review, and anything still unresolved at handoff.", "Fill the gap openly. State when you're entering the information and when the event happened. Don't invent an exact time or a response you can't remember." ], "one_thing": "Chart the whole escalation, not just whom you told. Include when, what you communicated, what they said back, and what you did next.", "what_goes_wrong": "You chart the notification, and the note stops there. But the concern may still be unresolved.\n\n*Charge aware* doesn't identify the concern or the response. Did you report mild nausea or a sudden change in consciousness? Did charge agree to call the clinician, actually make the call, or understand that you were calling? The next person reading the chart can't tell.\n\nYour note needs to answer more than whether you spoke up: **What did the recipient know, what remained unresolved, and what happened next?**\n\nA missing note doesn't prove the conversation never happened. It just leaves the chart without those details. No wording guarantees legal protection. You're aiming for an accurate account of your care that someone else can follow.", "rewrites": [ { "situation": "", "before": "Charge aware of low BP.", "after": "14:05: M. Lewis, RN, charge nurse, notified in person of BP 96/58, decreased from 126/72 at 13:00; HR 108 and new dizziness while sitting. Requested bedside reassessment and assistance contacting covering clinician. Lewis came to bedside at 14:07. Patient assisted to supine position; repeat BP 100/60, dizziness decreased. I contacted covering clinician Dr. Patel at 14:08 and reported findings." }, { "situation": "", "before": "MD paged. No response.", "after": "16:02: Dr. Patel paged regarding new confusion; requested immediate bedside assessment. 16:05: No callback received; patient remains newly confused. Rapid response activated per facility protocol; M. Lewis, RN, charge nurse, notified. 16:07: Rapid-response team at bedside; assessment findings and medication history communicated to team." }, { "situation": "", "before": "MD aware. No new orders.", "after": "11:20: Dr. Patel notified by telephone that pain remains 8/10, 45 minutes after prescribed analgesic; patient awake, RR 16/min. Requested review of pain-management plan. Dr. Patel advised no additional analgesic at this time and stated bedside assessment planned within 10 minutes. 11:28: Dr. Patel at bedside. 11:35: Pain 6/10 after repositioning; patient remains awake, RR 16/min." }, { "situation": "", "before": "Charge notified earlier.", "after": "09/12/2026 16:20 — Late entry for 09/12/2026 at approximately 14:05: Reported new dizziness while sitting and BP 96/58 to M. Lewis, RN, charge nurse, in person. Requested bedside assessment. Lewis stated she would assess the patient. I assisted patient back to supine position and repeated BP; reassessment documented in the 14:10 flowsheet. Exact conversation time not recalled. Communication omitted from earlier documentation." }, { "situation": "", "before": "Passed on to night shift.", "after": "19:05: Bedside handoff to K. Brown, RN. Reported persistent nausea, three episodes of emesis since 17:00, and telephone discussion with Dr. Patel at 18:50. Dr. Patel stated bedside review planned by 19:15; review has not yet occurred. Brown confirmed receipt of the pending review and follow-up plan. Charge nurse M. Lewis, RN, updated at 19:08 regarding unresolved concern." } ], "words_to_avoid": [ { "wording": "Charge aware", "why": "No identifiable recipient, content, or response", "instead": "Name and role, time, findings communicated, response" }, { "wording": "MD notified", "why": "Does not distinguish a page from an actual conversation", "instead": "Paged Dr. Patel at 16:02; no callback as of 16:05" }, { "wording": "Refused to help", "why": "Assigns motive without describing conduct", "instead": "Requested bedside review; Dr. Patel declined to come at that time; next escalation documented" }, { "wording": "No new orders", "why": "Leaves the clinical plan and your follow-up unclear", "instead": "Response received, reassessment findings, and next action" }, { "wording": "Will continue to monitor", "why": "Does not identify what needs reassessment", "instead": "Specific reassessment plan, followed by a timed entry of actual findings" }, { "wording": "Everyone knows", "why": "No traceable communication", "instead": "Each relevant recipient’s name, role, and contact time" } ], "cases": [ { "case": "Christus Health Gulf Coast d/b/a Christus St. John Hospital, and Christus St. John Hospital v. Alison Davidson", "url": "https://www.courtlistener.com/opinion/3204480/christus-health-gulf-coast-dba-christus-st-john-hospital-and-christus/", "court": "Texas Court of Appeals, Fourteenth District", "year": "2016", "quote": "", "what_it_shows": "The opinion describes expert reports that acknowledged some calls and physician read-backs. Those reports also criticized failures to follow up and escalate. The nursing expert’s criticisms included: > Nurses did not timely notify the rapid-response team, nurse manager or nurse director. That was an expert’s allegation summarized in the opinion. It was not a final finding of negligence. The appellate court reversed and remanded because the expert report did not adequately explain causation. Here's the distinction to keep in mind: evidence that some communication happened doesn't tell you what happened when nobody responded or the patient kept deteriorating." }, { "case": "Erin Reding v. Lubbock County Hospital District d/b/a University Medical Center", "url": "https://www.courtlistener.com/opinion/4737798/erin-reding-v-lubbock-county-hospital-district-dba-university-medical/", "court": "Texas Court of Appeals, Seventh District", "year": "2020", "quote": "", "what_it_shows": "Reding, an RN, reported concerns about a proposed mandatory on-call policy to the hospital’s legal department after human resources referred her there. The court affirmed dismissal of her Texas Whistleblower Act claim. Under that statute, the internal legal department was not an appropriate law-enforcement authority, and her belief that it qualified was not objectively reasonable. This was an employment-reporting case, not a ruling on bedside charting. The lesson here is narrow: documenting that you went up the internal ladder doesn't automatically give you a separate legal protection. Clinical escalation and statutory reporting protections are different questions." } ], "guidance": [ { "says": "Use your facility’s chain-of-command process to escalate care concerns.", "sources": [ { "name": "NCCHC", "url": "https://ncchc.org/defensive-documentation-for-nurses/" }, { "name": "NURSING.com", "url": "https://nursing.com/lesson/01-05-documenting-escalation-chain-of-command" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "your-own-notes", "title": "Your own notes are not automatically private", "search_title": "Keeping your own notes, texts and screenshots", "question": "Is anything you keep for yourself actually private?", "asked_as": "nurse personal notes discoverable text messages screenshots lawsuit", "cluster": "cover", "url": "https://shiftiswild.com/notes/your-own-notes/", "markdown_url": "https://shiftiswild.com/notes/your-own-notes.md", "summary": "You saved a screenshot, texted a coworker, or wrote your own account of a difficult shift. Now you want to know who could see it. Stop sharing it. Do not start deleting, rewriting, or moving things around on your own.", "key_points": [ "Personal storage does not guarantee privacy. Notes, texts, and screenshots may be requested in litigation if they are relevant. Being outside the chart does not put them out of reach.", "Do not clean up the originals. Get prompt instructions on secure handling and preservation. Do not delete, crop, or replace files on your own.", "Put missing care information in the clinical record. Use the approved correction or late-entry process and the actual entry time.", "Report misplaced patient information through the privacy process. Explain what happened without making another unnecessary copy.", "Keep personal learning notes general and nonidentifying. A reminder to review a procedure is one thing. A private, patient-by-patient backup chart is another." ], "one_thing": "Keeping something for yourself does not make it private. If it already exists, secure it, report it through the right process, and correct the record without rewriting the past.", "what_goes_wrong": "It is easy to mistake *outside the chart* for *outside the record of what happened*.\n\nYour phone note might include observations you never passed along to the care team. Your text might make an accusation the chart does not support. A screenshot might capture only part of a conversation. Keeping these things to yourself does not stop someone from requesting them as evidence.\n\nThree separate questions tend to get lumped together:\n\n- **Confidentiality:** Who is allowed to see or receive the information?\n- **Discoverability:** Can relevant information be obtained through litigation?\n- **Legal protection:** Does a particular protection limit disclosure?\n\nAn approved secure system addresses access and security. It does not settle the other two questions. But a request for information does not automatically give someone access to everything on your phone, either. Take questions about a specific request to qualified counsel.\n\nA separate account creates a more immediate problem: now you have two versions to reconcile. One says you notified the provider. The other says you sent a message and got no response. Those are not necessarily the same event.\n\nAn honest correction keeps the original, identifies the error, and explains the change. Quietly replacing it with a polished version loses that explanation.", "rewrites": [ { "situation": "", "before": "Personal phone note: MD ignored the low BP. Keeping this here to protect myself.", "after": "Chart late entry, if accurate: Late entry entered 09/13 at 09:15 for care at 02:10: BP 82/46; HR 122. Rapid response activated at 02:11. Dr. Lee notified by telephone at 02:12 and stated he was coming to bedside." }, { "situation": "", "before": "Chart: MD aware via Epic.", "after": "Chart: 14:05 secure chat sent to Dr. Lee reporting new nausea after oral medication. No acknowledgment received by 14:15; office called. At 14:18, Dr. Lee returned call and stated he would review medication orders." }, { "situation": "", "before": "Coworker text: Room 412 is a nightmare. Refused everything again.", "after": "Chart the relevant care facts instead: 10:00 patient declined scheduled acetaminophen, reporting pain 0/10. Medication not administered." }, { "situation": "", "before": "Personal reminder: Screenshot saved in case the chart changes.", "after": "Approved privacy-reporting channel, not a routine clinical note: At 16:20, I captured an EHR screen on my personal phone. The image includes patient identifiers. I have not sent it to anyone. Requesting instructions for secure handling and preservation." }, { "situation": "", "before": "Existing chart entry with the wrong time: 09:00 Dr. Lee notified by telephone.", "after": "Approved correction: Correction entered at 11:05: The earlier entry misstated the notification time. Dr. Lee was notified by telephone at 09:20, not 09:00." }, { "situation": "", "before": "Personal learning notebook: Room 412, Smith, septic patient whose family threatened a lawsuit.", "after": "General learning note: Review the sepsis escalation pathway before the next shift." } ], "words_to_avoid": [ { "wording": "For my protection / just in case", "why": "Explains your motive, not the care provided", "instead": "The observation, action, notification, and response" }, { "wording": "MD ignored me", "why": "Assumes intent", "instead": "Message sent at 14:05; no acknowledgment by 14:15; office called" }, { "wording": "Provider aware", "why": "Does not identify what was communicated or confirmed", "instead": "Name, time, method, information reported, and actual response" }, { "wording": "Refused everything", "why": "Turns one event into a blanket claim", "instead": "Name the specific medication or intervention declined" }, { "wording": "Always / never", "why": "Makes a claim beyond the event you observed", "instead": "The specific event and time" } ], "cases": [ { "case": "Rossbach v. Montefiore Medical Center", "url": "https://www.courtlistener.com/opinion/9422806/rossbach-v-montefiore-medical-center/", "court": "U.S. Court of Appeals for the Second Circuit", "year": "2023", "quote": "", "what_it_shows": "A registered nurse brought employment claims against her hospital and supervisors. One central piece of evidence was an image she said showed text messages from a supervisor. The district court found that she fabricated the messages, testified falsely about how they were created, and failed to preserve evidence to conceal the fabrication. The examination covered the image’s technical characteristics, its metadata, and inconsistencies in her account of the phones involved. The appellate court upheld the dismissal and the sanction against the nurse. It vacated the sanctions against her attorneys and sent that issue back because the wrong legal standard had been applied. This was not a nurse being penalized simply for saving messages. The case concerned fabrication, false testimony, and the handling of original evidence. Keep that distinction clear." }, { "case": "Nuvasive, Inc. v. Absolute Medical, LLC", "url": "https://www.courtlistener.com/opinion/9408239/nuvasive-inc-v-absolute-medical-llc/", "court": "U.S. Court of Appeals for the Eleventh Circuit", "year": "2023", "quote": "", "what_it_shows": "In a medical-device business dispute, discovery turned up texts sent to a witness while he was testifying in an arbitration. His testimony appeared to match answers suggested in those messages. The district court set aside the arbitration award on fraud grounds. The appellate court affirmed. The lesson is narrow: messages outside the formal proceeding became evidence about what happened inside it. These were employment and business disputes. Neither means that every nursing worksheet, incident report, or secure chat must be disclosed." } ], "guidance": [ { "says": "Keep identifiable patient information confidential, whether it is on paper, in an electronic file, or in an image.", "sources": [ { "name": "NursingEducation", "url": "https://nursingeducation.org/insights/documentation/" }, { "name": "Credenza", "url": "https://credenzahealth.com/career-advice/patient-privacy-nursing-guide" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "co-sign", "title": "You Already Co-Signed Something You Did Not See", "search_title": "What co-signing a nursing note actually means", "question": "What are you actually saying when you co-sign?", "asked_as": "cosign nursing student orientee witness signature responsibility", "cluster": "cover", "url": "https://shiftiswild.com/notes/co-sign/", "markdown_url": "https://shiftiswild.com/notes/co-sign.md", "summary": "Your name is already on the line. Maybe it was a consent, a student note, a CNA task, a med waste, or some checklist someone called routine.\nNow the question is simple: what did your signature actually say? And how do you fix the record without making the chart worse?", "key_points": [ "Do not sign anything else until you read the exact words above the signature button or signature line.", "Open the item you signed. Split it into three buckets: what you saw yourself, what someone told you, and what you assumed.", "Do not delete, overwrite, back-time, or quietly clean up the original entry.", "Tell your charge nurse, supervisor, or manager plainly: I signed [FORM/NOTE], but I did not personally observe [EVENT].", "If your facility process allows it, enter a factual addendum or correction with the real current date and time." ], "one_thing": "Your signature means the words above it, not what you hoped it meant.", "what_goes_wrong": "The common mistake is treating a co-signature like a favor.\n\nIt is not.\n\nYour signature sits under words. Those words matter.\n\nOne screen may only say you witnessed a patient’s signature. Another may say you reviewed and agreed with a student assessment. Another may say you personally watched a med waste. Another may say you verified that a provider completed a required certification.\n\nSame click. Different statement.\n\nIf someone reviews it later, they usually are not asking whether the unit was busy. They are not asking whether everyone clears the queue that way.\n\nThey ask concrete questions:\n\n- What did the attestation say?\n- Where were you when the event happened?\n- What did you personally observe?\n- What did you verify from a reliable source?\n- What did you do when you realized your signature said more than you meant?\n\nThat is why a clean-looking chart is not always safer. A clear correction often helps more than silence. It shows the real timeline and what you actually knew.", "rewrites": [ { "situation": "", "before": "Consent obtained. Patient understands procedure.", "after": "[DATE] [TIME] My signature appears on consent form for [PROCEDURE]. I witnessed patient sign the form at [TIME]. I did not conduct the risks, benefits, and alternatives discussion. Patient asked about [QUESTION] at [TIME]. Provider [NAME] notified and asked to return before procedure." }, { "situation": "", "before": "Reviewed and agree with student assessment.", "after": "[DATE] [TIME] Addendum: Nursing student [NAME] documented assessment at [TIME]. I did not directly observe that assessment. I assessed patient at [TIME]: alert and oriented x4, respirations even and unlabored, lung sounds clear bilaterally, dressing to [SITE] dry and intact, pain [SCORE]/10." }, { "situation": "", "before": "Ambulated 100 ft with walker, tolerated well.", "after": "[DATE] [TIME] CNA [NAME] reported patient ambulated approximately 100 ft with front-wheeled walker at [TIME]. I did not directly observe ambulation. I assessed patient at [TIME]: seated in chair, denies dizziness, denies shortness of breath, call light within reach." }, { "situation": "", "before": "Waste witnessed.", "after": "[DATE] [TIME] I observed [NAME], RN waste [MEDICATION] [AMOUNT] from [CONTAINER] into [LOCATION]. Amount matched MAR waste prompt. I did not observe medication administration." }, { "situation": "", "before": "Time-out completed.", "after": "[DATE] [TIME] I was present for time-out for [PROCEDURE]. Team stated patient name/DOB, procedure, site/laterality, and allergy status. Consent form was already in chart when I entered room. I did not witness the consent signature. Charge RN [NAME] notified." }, { "situation": "", "before": "Co-signed per charge nurse request.", "after": "[DATE] [TIME] Addendum to [NOTE/FORM]: I signed at [TIME] and later confirmed I did not directly observe [EVENT/TASK]. Charge RN [NAME] notified at [TIME]. Current patient status: [ASSESSMENT]." } ], "words_to_avoid": [ { "wording": "Reviewed and agree", "why": "Makes the other person’s note sound like your own finding", "instead": "Reviewed note; my assessment is documented separately" }, { "wording": "Verified", "why": "Implies you checked against a source", "instead": "Observed, compared with [SOURCE], or reported by [NAME/ROLE]" }, { "wording": "Witnessed", "why": "Implies you were physically present", "instead": "Patient reports, form found signed, or I was not present for signature" }, { "wording": "Consent obtained", "why": "Sounds like you handled informed consent", "instead": "Witnessed patient signature, provider notified for consent discussion" }, { "wording": "Completed", "why": "Hides who actually did the task", "instead": "[NAME/ROLE] completed; I observed [SPECIFIC PART]" }, { "wording": "Per policy", "why": "Does not say what happened", "instead": "Used [DEVICE/CHECK/PROCESS] at [TIME]" }, { "wording": "Tolerated well", "why": "Too vague when you did not see the event", "instead": "Denies dizziness/SOB, gait steady, no change in VS, or reported by [NAME]" }, { "wording": "Late charted as if on time", "why": "Makes the timeline muddy", "instead": "Late entry entered [CURRENT TIME] for care provided at [ACTUAL TIME]" } ], "cases": [ { "case": "Bon Secours St. Mary’s Hospital v. Department of Medical Assistance Services", "url": "https://www.courtlistener.com/opinion/8687122/bon-secours-st-marys-hospital-v-department-of-medical-assistance/", "court": "Richmond County Circuit Court", "year": "2014", "quote": "", "what_it_shows": "The dispute involved Medicaid certification and recertification documentation, including signatures and dates on forms and notes. The court wrote: “The court interprets the rules as requiring physicians to both sign and date the forms or notes at the time of admission and at the time of recertification.”" }, { "case": "Hogsett v. Parkwood Nursing & Rehabilitation Center, Inc.", "url": "https://www.courtlistener.com/opinion/8731534/hogsett-v-parkwood-nursing-rehabilitation-center-inc/", "court": "District Court, N.D. Georgia", "year": "2014", "quote": "", "what_it_shows": "Admission paperwork and an arbitration agreement were signed by the resident’s daughter on lines for a legal representative or caretaker. The court noted: “the parties agree that Hogsett had no legal status as her mother’s representative.”" }, { "case": "Benard Hubbard, II v. Nexion Health at Clinton, Inc. d/b/a Woodlands Rehabilitation and HealthCare Center, Minor Med Care P.A. and Timothy Duncan Estes, M.D.", "url": "https://www.courtlistener.com/opinion/10865751/benard-hubbard-ii-v-nexion-health-at-clinton-inc-dba-woodlands/", "court": "Mississippi Supreme Court", "year": "2026", "quote": "", "what_it_shows": "A son electronically signed admission and arbitration documents for his father. The court wrote that “the record contains insufficient evidence to establish Hubbard II’s legal authority to bind his father to arbitration”" }, { "case": "Rogers v. Roseville SH, LLC", "url": "https://www.courtlistener.com/opinion/6448190/rogers-v-roseville-sh-llc/", "court": "California Court of Appeal", "year": "2022", "quote": "", "what_it_shows": "A son signed a residency agreement as representative for his father, including an arbitration agreement. The appellate court concluded that “the trial court did not err in denying the petition to compel arbitration”" } ], "guidance": [ { "says": "Chart the care you personally performed or the event you personally saw. If someone else did it, say that person’s role instead of blurring who owns the entry.", "sources": [ { "name": "CNO", "url": "https://www.cno.org/standards-learning/practice-support/practice-support-faqs/designated-recorder-and-co-signing" }, { "name": "Oregon RN", "url": "https://cdn.ymaws.com/www.oregonrn.org/resource/resmgr/imported/RN%20signature.pdf" } ] }, { "says": "When the form or template does not tell the whole story, add a short factual note. Name who was involved, what was checked, and what you personally verified.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Charting-by-exception-the-legal-risks" }, { "name": "PMC", "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC9183775/" } ] }, { "says": "Do not chart care before it happens. Do not make another clinician’s assessment look like yours. Enter your own current factual note or addendum.", "sources": [ { "name": "ASRN", "url": "https://www.asrn.org/press-releases-item.html/?id=87" }, { "name": "NurseChartingPro", "url": "https://nursechartingpro.com/guides/charting-mistakes-that-can-cost-your-license" } ] } ], "ready_to_copy": "[DATE] [TIME] Addendum to [NOTE/FORM NAME] signed by me at [ORIGINAL DATE/TIME]: I did not directly observe [EVENT/ASSESSMENT/TASK] documented by [NAME/ROLE]. I reviewed the record after signature and notified [CHARGE RN/MANAGER NAME] at [TIME]. Current patient assessment/intervention by me: [WHAT YOU PERSONALLY ASSESSED OR DID]. [FOLLOW-UP COMPLETED OR NEEDED]. Entry made at actual time of discovery.\n[YOUR NAME], [CREDENTIALS]", "samples_are_written": true }, { "slug": "being-watched", "title": "When the family is recording and taking notes", "search_title": "Charting when you know you are being watched", "question": "How do you chart when the family is recording and taking notes?", "asked_as": "family recording nurse video patient room documenting complaint", "cluster": "cover", "url": "https://shiftiswild.com/notes/being-watched/", "markdown_url": "https://shiftiswild.com/notes/being-watched.md", "summary": "The phone is already up. Or someone is writing down every word. Now you still have to chart like a nurse, not like you’re scared.\nDon’t turn the note into a courtroom speech. Write the same clean, timed, clinical note you’d want to stand behind on any other shift.", "key_points": [ "Chart the care, not the audience.", "If the recording or note-taking changed privacy, safety, timing, or care, document that plainly.", "Don’t write a special defensive novel because the family is watching.", "Put clinical facts in the chart. Put visitor-policy or security issues in whatever facility process your workplace uses.", "If you’re charting late, say it’s late. Use the real event time and the real entry time." ], "one_thing": "Don’t chart like you’re being watched. Chart like the next nurse needs the truth.", "what_goes_wrong": "The usual mistake is overcorrecting because you feel watched.\n\nYou write more than you normally would. You add details that aren’t clinical. You explain your good intentions. You describe the family as hostile, suspicious, looking for a lawsuit, or trying to trap staff.\n\nIn the moment, that feels protective.\n\nLater, it works against you.\n\nNow the note looks different from your usual charting. It reads like you were defending yourself instead of documenting care. The facts get buried under commentary. And the questions people come back to are still simple: what time did it happen, what care was being done, was privacy affected, was care delayed, who did you notify, and how was the patient afterward.\n\nYour note does not need to beat the family’s notes. It needs to stand on its own.", "rewrites": [ { "situation": "", "before": "Daughter filming again. Family is hostile and trying to build a case. Explained everything and did everything correctly.", "after": "1045 Daughter at foot of bed holding phone with camera directed toward wound care area. Patient covered with sheet except treatment site. I paused wound care and asked daughter to stop recording during care for patient privacy. Daughter stopped recording at 1047. Charge RN M. Lee notified. Wound care completed per order. Patient denied increased pain." }, { "situation": "", "before": "Son questioning every medication and writing everything down. Seems paranoid.", "after": "0815 Son at bedside taking notes. Son asked purpose of furosemide. Reviewed medication name, ordered dose, indication listed in MAR, and common side effects. Patient accepted medication. No adverse reaction noted." }, { "situation": "", "before": "Family refused to stop videoing, so care was delayed because they would not cooperate.", "after": "1320 Before Foley catheter care, spouse had phone positioned toward patient and staff. I explained that catheter care exposes private areas and asked spouse to stop recording or step out. Spouse declined. Charge RN A. Patel notified at 1323 and came to room. Care resumed at 1328 after spouse stepped outside. Perineal care completed. Skin intact. Patient tolerated care." }, { "situation": "", "before": "Unable to assess properly because family was filming us during the rapid.", "after": "1902 Patient found short of breath with SpO2 84 percent on 2 L NC. Rapid response activated. Daughter standing near doorway holding phone with camera directed toward team. Charge RN asked daughter to move away from bedside. Oxygen increased to 6 L while awaiting provider. Patient transferred to ICU at 1935." }, { "situation": "", "before": "This nurse felt threatened and uncomfortable all shift because family documented everything.", "after": "1530 Daughter stated she was recording staff interactions. No threats made toward staff at that time. Charge RN notified. Scheduled assessment and medications completed. Patient alert and oriented x3, respirations even, call light within reach." }, { "situation": "", "before": "Family keeps interrupting care and accusing staff of neglect.", "after": "1715 Son asked why patient had not received dinner tray. Checked meal delivery list and notified dietary at 1718. Tray delivered at 1730. Patient ate approximately 50 percent of meal with assistance." } ], "words_to_avoid": [ { "wording": "hostile", "why": "Labels emotion instead of behavior", "instead": "raised voice, blocked doorway, declined to step out, continued recording after request" }, { "wording": "trying to sue", "why": "Guessing motive", "instead": "taking notes at bedside, recording with phone, asked for names of staff present" }, { "wording": "paranoid", "why": "Insulting and nonclinical unless it is an assessed symptom", "instead": "asked repeated questions about medications and plan of care" }, { "wording": "noncompliant family", "why": "Vague and blaming", "instead": "spouse declined request to stop recording during catheter care" }, { "wording": "I did everything correctly", "why": "Sounds defensive and adds no clinical fact", "instead": "care completed per order; patient tolerated; provider notified" }, { "wording": "educated extensively", "why": "Too vague", "instead": "reviewed medication name, dose, purpose, side effects, and when to call staff" }, { "wording": "threatened", "why": "Use only if there was an actual threat", "instead": "no threats made, or document the specific statement or behavior through facility process" }, { "wording": "refused to cooperate", "why": "Too broad", "instead": "declined to step out, declined to lower phone, declined to leave bedside during care" } ], "cases": [ { "case": "Patterson v. Beth Abraham Nursing Home", "url": "https://www.courtlistener.com/opinion/8403743/patterson-v-beth-abraham-nursing-home/", "court": "Appellate Division of the Supreme Court of the State of New York", "year": "2022", "quote": "many of the relevant facts concerning the decedent's care and treatment at defendant's facility are contained in the medical records prepared by defendant's staff", "what_it_shows": "" }, { "case": "Craig v. St. Barnabas Nursing Home", "url": "https://www.courtlistener.com/opinion/6188275/craig-v-st-barnabas-nursing-home/", "court": "Appellate Division of the Supreme Court of the State of New York", "year": "2015", "quote": "The medical records support the nursing home’s expert’s opinion that decedent’s skin ulcers and other complications were unavoidable and the result of preexisting conditions, as well as other risk factors", "what_it_shows": "" }, { "case": "Howell v. Park E. Care & Rehab.", "url": "https://www.courtlistener.com/opinion/4501827/howell-v-park-e-care-rehab/", "court": "Ohio Court of Appeals", "year": "2018", "quote": "Documents relative to [L.W.], including nursing home chart, medical records, physician notes, nurse statements and notes, progress notes, documentation of activities of daily living, assessment reports, incident/accident reports, physical therapy, administration of narcotics, dietary records, communications about [L.W.], etc.", "what_it_shows": "The appellate court reversed and remanded for an in camera review of disputed documents. The bedside lesson is simple: ordinary facility records can become the thing everyone fights over" } ], "guidance": [ { "says": "Chart only what you personally observed, assessed, did, or were told. Keep other people’s conclusions out of your note.", "sources": [ { "name": "ASRN", "url": "https://www.asrn.org/journal-chronicle-nursing/341-charting-and-documentation.html" }, { "name": "GCU", "url": "https://www.gcu.edu/blog/nursing-healthcare/how-write-nursing-notes" } ] }, { "says": "Chart as close to the event as you reasonably can. If the entry is not real time, make the timing clear.", "sources": [ { "name": "GCU", "url": "https://www.gcu.edu/blog/nursing-healthcare/how-write-nursing-notes" }, { "name": "Berxi", "url": "https://www.berxi.com/resources/articles/nurses-notes/" } ] }, { "says": "Keep the note objective: observations, interventions, information provided, and patient response.", "sources": [ { "name": "Nursa", "url": "https://nursa.com/blog/nurse-charting-documentation-made-easy-with-examples" }, { "name": "ASRN", "url": "https://www.asrn.org/journal-chronicle-nursing/341-charting-and-documentation.html" } ] }, { "says": "Use the normal charting structure your workplace expects, such as SOAP or narrative sections. Don’t write a special defensive story.", "sources": [ { "name": "CareerStaff", "url": "https://www.careerstaff.com/clinician-life-blog/nursing/charting-in-nursing-dos-and-donts/" }, { "name": "Host Healthcare", "url": "https://www.hosthealthcare.com/blog/nurse-charting-tips-mistakes-to-avoid/" } ] } ], "ready_to_copy": "[DATE] [TIME] During [CARE/PROCEDURE], [FAMILY MEMBER/NAME] was at bedside holding phone with camera directed toward [PATIENT CARE AREA/STAFF/PATIENT]. Patient privacy concern present due to [EXPOSED BODY AREA/PROCEDURE/PHI DISCUSSION/OTHER]. I paused care at [TIME] and asked [FAMILY MEMBER/NAME] to [STOP RECORDING/STEP OUT] during care. [FAMILY MEMBER/NAME] [STOPPED RECORDING/STEPPED OUT/DECLINED]. Charge RN [NAME] notified at [TIME]. [CARE/PROCEDURE] [RESUMED/COMPLETED/DELAYED] at [TIME]. Patient response: [PATIENT RESPONSE]. Current patient status: [OBJECTIVE STATUS].", "samples_are_written": true }, { "slug": "med-error-disclosure", "title": "Charting the conversation after a medication error", "search_title": "Charting the conversation after a medication error", "question": "What should I write after participating in the team's disclosure of a medication error to a patient or surrogate, beyond 'family notified', to capture who participated, what was explained, and the questions and next steps discussed?", "asked_as": "(site:allnurses.com OR site:reddit.com/r/nursing) medication error disclosure patient family nursing documentation", "cluster": "cover", "url": "https://shiftiswild.com/notes/med-error-disclosure/", "markdown_url": "https://shiftiswild.com/notes/med-error-disclosure.md", "summary": "After a team disclosure, *family notified* tells you someone made contact. It doesn't tell you what was said. Write a short account of who took part, what the patient or surrogate was told, what they asked, and who will handle the next steps.", "key_points": [ "Identify the conversation: Record the date, time, whether you met at the bedside or by phone/video, participants’ names and roles, and who led the discussion.", "Summarize the explanation: Include the confirmed medication error, current findings, possible effects discussed, and treatment or monitoring plan. Say who explained what.", "Capture the patient’s or surrogate’s side: What did they ask, express concern about, or request? Document their responses and any understanding they demonstrated.", "Make follow-up specific: Name the unanswered questions, who will respond, and when the next update is planned.", "Stay within what you know: Chart the part you attended and your own actions. Keep confirmed facts separate from explanations still under review." ], "one_thing": "Chart who took part, what was explained, what the patient or surrogate asked, and who will do what next. Not just that someone was notified.", "what_goes_wrong": "*Family notified; questions answered* sounds finished. But the next nurse still doesn't know which family member took part, whether the patient was included, what was explained, or which questions need attention.\n\nKeep the sources separate. Your assessment, the physician’s explanation, and a family member’s concern are different kinds of information. Say where each came from. And a normal assessment at the time of the conversation doesn't rule out later effects from the error.\n\nYou don't need a transcript. You need enough detail for the next clinician to pick up the discussion without guessing.", "rewrites": [ { "situation": "", "before": "Family notified.", "after": "06/10/2026, 1220: Bedside disclosure with patient, A. Patel, MD, hospitalist, and this RN. Daughter R. Chen participated by speakerphone at patient’s request. Dr. Patel led discussion." }, { "situation": "", "before": "Medication issue discussed. No harm.", "after": "Dr. Patel explained that insulin lispro 8 units subcutaneously was administered at 1200 instead of the ordered 4 units. Dr. Patel acknowledged the medication error, apologized, and discussed the risk of hypoglycemia and glucose-monitoring plan. At 1220, patient alert and denies shakiness or dizziness; point-of-care glucose 146 mg/dL. Dr. Patel explained that continued monitoring was needed." }, { "situation": "", "before": "Questions answered.", "after": "Patient asked whether the additional insulin could cause low blood sugar. Dr. Patel explained that it could and reviewed the monitoring plan. Daughter asked how the incorrect dose occurred. Dr. Patel stated that the cause had not yet been established and would need further review." }, { "situation": "", "before": "Patient verbalized understanding.", "after": "After instructions were reviewed, patient restated that sweating, shakiness, or dizziness should be reported immediately using the call light. Patient demonstrated call-light use. Daughter requested a written explanation of the monitoring plan; request relayed to Dr. Patel at 1230." }, { "situation": "", "before": "Will continue to monitor.", "after": "Glucose monitoring to continue per active orders. Dr. Patel stated he would return by 1400 to review results and provide an update on the daughter’s unanswered question about how the error occurred, including whether further review was still needed. Patient and daughter informed of planned update." }, { "situation": "", "before": "MD disclosed error; family aware.", "after": "Joined bedside discussion at 1228. Heard Dr. Patel review the glucose-monitoring plan and answer the patient’s question about symptoms to report. Initial explanation occurred before this RN arrived and was not witnessed by this RN." } ], "words_to_avoid": [ { "wording": "Harmless / no harm done", "why": "Turns a current assessment into a broad conclusion about outcome.", "instead": "Time-specific findings and the monitoring or reassessment plan." }, { "wording": "Family aware", "why": "Leaves the recipient and content unclear.", "instead": "Participant’s name and role, information explained, and response." }, { "wording": "Understands everything", "why": "Claims more than a nod or acknowledgment demonstrates.", "instead": "What the patient or surrogate accurately restated, or what needs clarification." }, { "wording": "All questions answered", "why": "Hides pending questions and does not preserve the answers given.", "instead": "The main questions, who answered, and any unresolved issue." }, { "wording": "Pharmacy’s fault / nurse was careless", "why": "Substitutes blame or an unconfirmed cause for established facts.", "instead": "The verified medication discrepancy and the explanation actually given, with attribution." }, { "wording": "Will follow up", "why": "Does not identify an owner or time.", "instead": "Who will provide the next update and the planned time or trigger." } ], "cases": [ { "case": "Dailey v. Methodist Medical Center", "url": "https://www.courtlistener.com/opinion/1848408/dailey-v-methodist-medical-center/", "court": "Court of Appeals of Mississippi", "year": "2001", "quote": "", "what_it_shows": "The opinion described alleged events that included a disputed infusion-rate entry and changing explanations to the family after the wrong medication was discovered. The family received reassurance that the medication was harmless, a possible labeling explanation, and a later apology. The appellate court reversed the summary judgments and remanded for trial. It did not make a final finding of liability. This case isn't a nursing-note template. It shows why your note needs to distinguish what was observed, what someone explained, and what was clarified later. A notification statement loses those distinctions." } ], "guidance": [ { "says": "Identify who on the team should take part in the disclosure.", "sources": [ { "name": "NCBI Bookshelf", "url": "https://www.ncbi.nlm.nih.gov/books/NBK2652/" }, { "name": "EMRA", "url": "https://www.emra.org/difficult-conversations-disclosing-errors" } ] }, { "says": "Tell the patient or family plainly that an error occurred. Don't leave them to infer it.", "sources": [ { "name": "AMA Journal of Ethics", "url": "https://journalofethics.ama-assn.org/article/disclosing-error-patient-physician-patient-communication/2005-08" }, { "name": "EMRA", "url": "https://www.emra.org/difficult-conversations-disclosing-errors" } ] } ], "ready_to_copy": "", "samples_are_written": true }, { "slug": "wrong-login", "title": "When Charting Happened Under the Wrong Login", "search_title": "", "question": "What should I write and who should I notify if care was documented in the EHR under the wrong user, shared password, or incorrect account?", "asked_as": "nurse charted under wrong login shared password EHR documentation what to do", "cluster": "cover", "url": "https://shiftiswild.com/notes/wrong-login/", "markdown_url": "https://shiftiswild.com/notes/wrong-login.md", "summary": "You gave the care. The EHR shows the wrong person, a shared account, or the wrong user session.\nDo not panic. Do not write a dramatic note. Fix the clinical record. Then notify the people who can fix the access problem.", "key_points": [ "Stop charting in the wrong session. Log out. Log back in under your own account. Do not keep working under the incorrect login.", "Do not delete, overwrite, backdate, or ask the other user to clean it up for you. Use your facility’s EHR correction or addendum process.", "In the patient chart, stick to the care facts: what was done, when, by whom, patient response, and that the entry was made under an incorrect EHR user account if that is needed to clarify attribution.", "Notify your charge nurse or supervisor, your manager if required, and the EHR help desk or IT/security team. Notify privacy/compliance if there was shared password use, possible unauthorized access, or PHI viewed under the wrong access.", "Keep the ticket number or report number in the right place. Do not save PHI screenshots or personal copies to prove what happened." ], "one_thing": "Fix the record in your own name, report the access problem through the right channels, and do not make a second wrong-login entry to clean up the first.", "what_goes_wrong": "The usual mistake is trying to make the chart look clean. So someone uses the wrong account again. Or deletes the entry. Or writes a long self-defense note in the patient record.\n\nThat creates a second problem.\n\nThe EHR already has an audit trail showing user, time, and action. If you keep charting under the wrong login, the trail gets messier. If you write a personal explanation in the patient chart, the record fills up with workflow details instead of patient care facts.\n\nThe patient record needs a clean correction of the care documentation. The login, password, and access issue goes to the supervisor, EHR help desk, IT/security, and privacy/compliance process.", "rewrites": [ { "situation": "", "before": "0915 0800 meds were given by me but charted on Jamie’s login by mistake. Please delete Jamie’s charting.", "after": "0915 Addendum to 0802 MAR documentation: At 0802, [YOUR NAME], RN, administered lisinopril 10 mg PO and metoprolol tartrate 25 mg PO. Patient identifiers and ordered parameters verified before administration. MAR documentation for this administration was entered under an incorrect EHR user account. Charge RN [NAME] notified at 0910; EHR correction request submitted per unit process." }, { "situation": "", "before": "2010 Assessment was charted under Dr. Lee because she left the computer open. It was my assessment, not hers.", "after": "2010 Addendum to 1938 assessment documentation: Focused respiratory assessment performed by [YOUR NAME], RN, at 1930. Breath sounds clear bilaterally; respirations even and unlabored; SpO2 96% on room air. Assessment documentation was entered during an incorrect EHR user session. Charge RN [NAME] and EHR help desk notified; ticket [NUMBER]." }, { "situation": "", "before": "1045 I used the charge nurse login because my password would not work. Dressing change done.", "after": "1045 Late entry for 0955: Right lower leg dressing changed by [YOUR NAME], RN, using sterile technique. Wound bed pink; small serous drainage; no odor noted. New sterile gauze and wrap applied. Patient tolerated procedure. Initial documentation for this care was entered under an incorrect EHR user account. Nurse manager and help desk notified." }, { "situation": "", "before": "1530 Vitals are under the CNA’s name but I took them. No harm done.", "after": "1530 Addendum to 1500 flowsheet documentation: Vital signs obtained by [YOUR NAME], RN, at 1500: BP 128/76 left arm sitting, HR 84, RR 18, temp 98.4 F oral, SpO2 97% on room air. Values were entered under an incorrect user account; supervisor notified at 1525." }, { "situation": "", "before": "I clicked around in the chart but I did not do anything bad.", "after": "For privacy/compliance report, not the patient chart: On [DATE] at approximately [TIME], I accessed [PATIENT/ENCOUNTER] while logged in as [USER]. I viewed [SECTIONS VIEWED]. I did not enter, change, print, download, or disclose information. I notified [SUPERVISOR] at [TIME] and am submitting this report for review." } ], "words_to_avoid": [ { "wording": "accidentally", "why": "Reads like an excuse and still does not explain the record clearly", "instead": "entered under an incorrect EHR user account" }, { "wording": "delete this", "why": "Points toward removal when you need a traceable correction", "instead": "correction request submitted per facility process" }, { "wording": "everyone does this", "why": "Not a patient care fact", "instead": "Omit from the chart; report workflow concern separately" }, { "wording": "no harm done", "why": "A conclusion, not an assessment", "instead": "patient assessed; objective findings documented" }, { "wording": "HIPAA violation", "why": "Legal label; usually not needed in the clinical note", "instead": "possible privacy/access issue reported to privacy/compliance" }, { "wording": "borrowed password", "why": "Access detail usually belongs in IT/security or compliance report", "instead": "incorrect user session identified" }, { "wording": "falsified", "why": "Accusation or conclusion", "instead": "entry attribution incorrect" }, { "wording": "not my fault", "why": "Self-defense, not patient care", "instead": "state what happened, who was notified, and what correction was requested" }, { "wording": "disregard", "why": "Vague and easy to misunderstand", "instead": "see addendum dated [DATE] [TIME] for corrected documentation" } ], "cases": [], "guidance": [ { "says": "Keep EHR credentials individual. Do not share an EMR ID, username, or password, and do not let someone else document under yours.", "sources": [ { "name": "nurse.com", "url": "https://www.nurse.com/blog/protect-yourself-with-tips-proper-documentation/" }, { "name": "AIHC", "url": "https://aihc-assn.org/is-sharing-ehr-passwords-a-problem/" } ] }, { "says": "Before you enter data, confirm that you are in the intended patient record. Wrong-record documentation is a known charting error and can be hard to unwind.", "sources": [ { "name": "AMN Healthcare", "url": "https://www.amnhealthcare.com/blog/nursing/contract/common-nurse-charting-mistakes-to-avoid/" }, { "name": "MedicalHero", "url": "https://medicalhero.com/common-charting-errors-in-nursing/" } ] }, { "says": "Keep documentation factual and complete enough to show what care occurred, who did it, and when. Save workflow explanations and reporting for the right channel.", "sources": [ { "name": "Medcom", "url": "https://medcominc.com/medical-errors/prevent-documentation-errors-nursing/" }, { "name": "WTCS Pressbooks", "url": "https://wtcs.pressbooks.pub/nurseassist/chapter/1-5-documenting-and-reporting/" } ] } ], "ready_to_copy": "[DATE] [TIME] Addendum/late entry for care provided on [DATE] at [TIME]: [YOUR NAME], [CREDENTIALS], performed/provided [CARE PROVIDED]. Objective findings/interventions: [ASSESSMENT FINDINGS AND INTERVENTIONS]. Patient response: [PATIENT RESPONSE]. Documentation for this care was previously entered under an incorrect EHR user account/session. [CHARGE RN/SUPERVISOR NAME] notified at [TIME]. EHR correction request submitted per facility process, [TICKET/REPORT NUMBER].", "samples_are_written": true }, { "slug": "calling-out", "title": "Calling Out Without Giving Them a Write-Up to Build", "search_title": "Calling out sick as a nurse: what to say and what to keep", "question": "How do I call out so it cannot be turned into a write-up later?", "asked_as": "nurse call out sick policy what to say write up attendance", "cluster": "shift", "url": "https://shiftiswild.com/notes/calling-out/", "markdown_url": "https://shiftiswild.com/notes/calling-out.md", "summary": "Calling out is not just saying you are sick. You still have to use the attendance process your facility put in the policy. Then leave a clean trail: who you notified, when, how, and what they said back.\nNo wording makes you write-up-proof. But a complete call-out record gives management a lot less room to turn a real call-out into no call/no show later.", "key_points": [ "Use the required method first: staffing line, charge nurse, house supervisor, manager, app, or whatever your policy says.", "Call before the deadline in the policy. If it says 2 hours before shift, 90 minutes is not close enough.", "Do not rely on a coworker, hallway comment, group text, or voicemail unless the policy says that counts.", "Keep the reason short and true: illness, personal emergency, unable to work safely, or the exact reason your policy requires.", "Write down the name, role, time, number used, and whether the person confirmed the call-out." ], "one_thing": "Call the right person, before the deadline, in the required way. Then write down who confirmed it.", "what_goes_wrong": "The usual mistake is thinking everyone already knows.\n\nYou told staffing yesterday. You texted the charge nurse. You mentioned your fever to the manager. Your leave paperwork is pending. Your schedule says requested off. The unit was overstaffed and someone told you not to come in.\n\nAll of that may be true. It still may not match the attendance policy.\n\nAttendance systems are usually just checkboxes: scheduled shift, required notice given, correct person notified, correct method used, reason given if required, expected duration given if required. If one box is blank, the later record can become no call/no show even when you were actually sick or trying to handle it the right way.", "rewrites": [ { "situation": "", "before": "`Sick today. Sorry.`", "after": "`Call-out notice for [DATE] [SHIFT]. I am ill and unable to work. Notified [NAME], [ROLE], by phone at [TIME] using [PHONE NUMBER]. [NAME] confirmed receipt.`" }, { "situation": "", "before": "`I left a message.`", "after": "`At [TIME], called [REQUIRED NUMBER]. No answer. Voicemail left with my name, unit, scheduled shift, and callback number. Because policy requires live notification, I also called [BACKUP NAME/ROLE] at [TIME] and spoke with [NAME].`" }, { "situation": "", "before": "`I told staffing I’m out all week.`", "after": "`Daily call-out update for [DATE] [SHIFT]. I am still unable to work due to illness. Notified [NAME/ROLE] at [TIME]. Expected next update: [DATE/TIME].`" }, { "situation": "", "before": "`Charge said I was canceled.`", "after": "`Facility cancellation clarification: at [TIME], [NAME/ROLE] called and stated I should not report for [DATE] [SHIFT] due to [LOW CENSUS/OVERSTAFFING]. I asked whether this is a facility cancellation rather than my call-out. [NAME] confirmed [RESPONSE].`" }, { "situation": "", "before": "`FMLA pending, not coming in.`", "after": "`Leave paperwork is pending with [HR/EMPLOYEE HEALTH]. Until written approval is received, I am following the attendance policy. Today at [TIME], I notified [NAME/ROLE] that I am unable to work [DATE] [SHIFT].`" }, { "situation": "", "before": "`I already requested that day off.`", "after": "`Schedule question for [DATE] [SHIFT]: my prior request-off was submitted on [DATE] to [NAME/ROLE]. Current schedule still shows me assigned. I notified [NAME/ROLE] at [TIME] and asked whether I am expected to report. [NAME] stated [RESPONSE].`" } ], "words_to_avoid": [ { "wording": "`someone`", "why": "No accountable recipient", "instead": "`[NAME], [ROLE]`" }, { "wording": "`I told them`", "why": "No time, method, or person", "instead": "`Called [NAME/ROLE] at [TIME] using [PHONE NUMBER]`" }, { "wording": "`left word`", "why": "Unclear whether policy allows that", "instead": "`Voicemail left at [TIME]; backup notification made to [NAME/ROLE] at [TIME]`" }, { "wording": "`out for a while`", "why": "No shift dates or next update", "instead": "`Unable to work [DATE] [SHIFT]; next update by [DATE/TIME]`" }, { "wording": "`probably`", "why": "Sounds uncertain", "instead": "`Expected update is [DATE/TIME]`" }, { "wording": "`they know I’m sick`", "why": "Assumption is not notice", "instead": "`Notified [NAME/ROLE] today at [TIME]`" }, { "wording": "`personal stuff`", "why": "Invites unnecessary detail", "instead": "`Personal emergency; unable to work [DATE] [SHIFT]`" }, { "wording": "`no call/no show`", "why": "Do not label yourself that way if you attempted notice", "instead": "`Called [NUMBER] at [TIME]; result was [NO ANSWER/VOICEMAIL/SPOKE WITH NAME]`" }, { "wording": "`FMLA`", "why": "Pending leave is not the same as today’s call-out", "instead": "`Leave request submitted [DATE]; call-out completed under attendance policy on [DATE/TIME]`" }, { "wording": "`I texted charge`", "why": "May not match policy", "instead": "`Used required call-out method: [METHOD]. Text sent only as follow-up at [TIME].`" } ], "cases": [ { "case": "Phillips v. Unemployment Insurance Appeals Board", "url": "https://www.courtlistener.com/opinion/3217651/phillips-v-unemployment-insurance-appeals-board/", "court": "Superior Court of Delaware", "year": "2016", "quote": "If your absence continues for more than one day, call your supervisor each day.", "what_it_shows": "The employee had medical issues and FMLA paperwork involved. The court still focused on the employer’s attendance policy and the daily-call requirement Practical point: if the policy says call every day, one call for a block of dates may not be enough." }, { "case": "Thompson v. Unemployment Compensation Board of Review", "url": "https://www.courtlistener.com/opinion/5136471/thompson-v-unemployment-compensation-board-of-review/", "court": "Commonwealth Court of Pennsylvania", "year": "1999", "quote": "Claimant testified that she did call off that day to Kelly Pashok.", "what_it_shows": "A nurse aide was out with the flu. The court reversed the denial of benefits after looking at illness, replacement-worker requirements, and whether there was solid evidence that she failed to call off Practical point: the name of the person you called can matter later." }, { "case": "Wis. Dep’t of Workforce Dev. v. Wis. Labor & Indus. Review Comm’n", "url": "https://www.courtlistener.com/opinion/8284479/wis-dept-of-workforce-dev-v-wis-labor-indus-review-commn/", "court": "Wisconsin Supreme Court", "year": "2018", "quote": "call in 2 hours ahead of time", "what_it_shows": "A registered nurse in a probationary period missed a shift with flu-like symptoms and did not notify the employer before the required deadline. The court treated the signed attendance policy as important Practical point: if your policy has a time window, meet the window." }, { "case": "Stubbs v. ICare Management, LLC", "url": "https://www.courtlistener.com/opinion/4764395/stubbs-v-icare-management-llc/", "court": "Connecticut Appellate Court", "year": "2020", "quote": "She testified that she had received a phone call from one of the defendants’ employees, whom she could not identify, telling her not to report to work on those dates because the defendants were overbooked with CNAs.", "what_it_shows": "A CNA said she had been told not to report because the facility was overbooked with CNAs. The appellate court allowed parts of her employment claims to continue because there were factual disputes, including what happened around the alleged no call/no show Practical point: if someone tells you not to come in, get the name, role, and confirmation that this is a facility cancellation, not your call-out." }, { "case": "Roark v. Pocahontas Nursing & Rehabilitation", "url": "https://www.courtlistener.com/opinion/1441475/roark-v-pocahontas-nursing-rehabilitation/", "court": "Court of Appeals of Arkansas", "year": "2006", "quote": "Roark acknowledged that there was a rule that required employees to call into work at least two hours beforehand if they were going to be absent", "what_it_shows": "A CNA had previously requested days off, later returned on light duty, and was terminated after a no call/no show dispute. The court affirmed the Commission’s decision Practical point: a prior request-off note may not protect you if your assignment, supervisor, or return-to-work status changed." } ], "guidance": [ { "says": "Keep the record factual and neutral: what happened, who got the notice, when, and what response you received. Leave out labels and opinions.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" }, { "name": "RN-Nurse", "url": "https://rn-nurse.com/documentation-dos-and-donts-for-nurses/" } ] }, { "says": "When a notification matters, document the name, time, and communication trail. Do not just write that someone was notified.", "sources": [ { "name": "Nurse.org", "url": "https://nurse.org/news/nursing-documentation-mistakes/" }, { "name": "Reddit", "url": "https://www.reddit.com/r/nursing/comments/slxdpa/do_you_name_drop_in_your_notes/" } ] }, { "says": "Do not use a patient chart to argue about staffing, coworkers, management, or attendance. Use the proper employment channel instead.", "sources": [ { "name": "Medical Economics", "url": "https://www.medicaleconomics.com/view/never-feud-nurses-patients-chart" }, { "name": "allnurses", "url": "https://allnurses.com/nurses-notes-guidelines-on-what-t519366/" } ] }, { "says": "Avoid shorthand your facility has not approved. Unclear abbreviations make later review harder.", "sources": [ { "name": "TextExpander", "url": "https://textexpander.com/blog/examples-of-nursing-documentation-errors" }, { "name": "Nursing School of Success", "url": "https://nursingsos.com/episode152/" } ] } ], "ready_to_copy": "This is [NAME], [ROLE] on [UNIT]. I am scheduled for [DATE] from [SHIFT START] to [SHIFT END]. I am ill and unable to work this shift.\n\nI am calling at [TIME] through the required call-out process. My expected duration is [TODAY ONLY/THROUGH DATE/UNKNOWN; I WILL UPDATE BY DATE AND TIME].\n\nPlease confirm your name and that this call-out is recorded.", "samples_are_written": true }, { "slug": "abandonment-myth", "title": "Not Showing Up Is Not Patient Abandonment", "search_title": "Is a no-call no-show patient abandonment? What boards say", "question": "If I do not come in, can they take my licence for abandonment?", "asked_as": "patient abandonment nurse no call no show license board definition", "cluster": "shift", "url": "https://shiftiswild.com/notes/abandonment-myth/", "markdown_url": "https://shiftiswild.com/notes/abandonment-myth.md", "summary": "If you miss a shift, your employer may treat it as an attendance issue. That is not the same thing as leaving after you accepted responsibility for assigned patients. Your charting job is simple: make the timeline clear.", "key_points": [ "If you did not get report or accept a patient assignment, document an absence or call-out. Not patient abandonment.", "Notify the right person as early as you can. Use your facility’s process.", "Write the basics: date, time, who you notified, how you notified them, and whether you had accepted report.", "If you already accepted report, do not just leave. Tell charge or the supervisor, give report, and document who accepted care.", "Stay away from loaded words. Facts carry more weight than labels." ], "one_thing": "No report and no accepted assignment belongs in a different record than leaving after you already took responsibility for patients.", "what_goes_wrong": "The mistake is letting the record repeat the employer’s label instead of showing what actually happened.\n\nA no-call/no-show, late call-out, or refusal to pick up extra hours is an attendance and staffing event. Patient abandonment is about patient responsibility: Did you accept the assignment? Did you receive report? Were you already caring for those patients? Did you transfer care to another qualified person before leaving?\n\nIf the only note says RN abandoned shift, the next person has to guess. A better note answers the real questions: whether report was given, whether the assignment was accepted, who was notified, and how coverage was arranged.", "rewrites": [ { "situation": "", "before": "0700: RN Smith no call/no show, abandoned Hall A.", "after": "0710: RN Smith not present for scheduled 0700 shift. No report given to RN Smith and no patient assignment accepted by RN Smith. Charge RN redistributed Hall A assignments to RN Jones and RN Patel. Nursing supervisor Brown notified at 0712." }, { "situation": "", "before": "Called out sick. They said I abandoned patients.", "after": "0542: I notified Charge RN Lee by phone that I am unable to report for the 0700 shift due to illness. I had not received report, accepted keys, or accepted a patient assignment for this shift." }, { "situation": "", "before": "Refused to stay. Possible abandonment.", "after": "1915: Bedside report for rooms 301-304 completed to RN Kim. MAR, pending labs, wound care due at 2200, and fall precautions reviewed. Charge RN Davis notified I am unable to accept additional 1900-2300 coverage." }, { "situation": "", "before": "Refused unsafe assignment and left.", "after": "0648: Proposed assignment reviewed before report: 8 telemetry patients, including 2 insulin drips. I had not accepted report. Notified Charge RN Moore and Supervisor Grant; requested revised assignment or additional licensed staff. Remained available for direction until 0715." }, { "situation": "", "before": "Left sick. My notes were done.", "after": "0340: Vomiting and dizziness reported to Charge RN Allen. Verbal report for rooms 212-216 given to RN Rivera at 0350, including pending 0400 vital signs and IV antibiotic due at 0430. RN Rivera accepted assignment. Charge RN confirmed coverage. Left unit at 0405." } ], "words_to_avoid": [ { "wording": "Abandoned", "why": "Legal conclusion, not a fact", "instead": "Did not report for shift; no assignment accepted" }, { "wording": "Walked off", "why": "Sounds sudden and vague", "instead": "Left unit at [TIME] after [HANDOFF/SUPERVISOR NOTIFICATION]" }, { "wording": "Refused assignment", "why": "Blurs whether report was accepted first", "instead": "Did not accept assignment; requested supervisor review before report" }, { "wording": "No call/no show", "why": "HR shorthand; does not explain patient responsibility", "instead": "RN not present by [TIME]; no report given; coverage arranged" }, { "wording": "My patients were fine", "why": "Opinion, not handoff documentation", "instead": "Patient status and pending tasks reported to [NAME] at [TIME]" }, { "wording": "Unsafe", "why": "Too broad by itself", "instead": "Patient count, acuity, competencies, resources requested" }, { "wording": "Threatened my license", "why": "Emotional and not patient-care focused", "instead": "[NAME/TITLE] notified RN that facility may report event; RN stated factual timeline" } ], "cases": [ { "case": "Miller v. Tennessee Board of Nursing", "url": "https://www.courtlistener.com/opinion/2344679/miller-v-tennessee-board-of-nursing/", "court": "Court of Appeals of Tennessee", "year": "2007", "quote": "There is no dispute that Ms. Miller accepted the obligation to care for four to five patients when she reported for work at Cookeville Regional Medical Center’s med/surg unit.", "what_it_shows": "Why it matters here: the nurse had already accepted patient responsibility. That is different from never coming in and never taking report." }, { "case": "Ruby Clinkscale v. St. Therese of New Hope", "url": "https://www.courtlistener.com/opinion/811785/ruby-clinkscale-v-st-therese-of-new-hope/", "court": "Court of Appeals for the Eighth Circuit", "year": "2012", "quote": "On October 22, 2010, St. Therese registered a complaint regarding Clinkscale with the Minnesota Board of Nursing, alleging that Clinkscale had \"refused work assignment & walked out.\"", "what_it_shows": "Why it matters here: the employer’s wording became part of the later record. The cleaner your timeline, the less room you leave for vague labels." }, { "case": "W.L. Ives, M.D. v. BPOA", "url": "https://www.courtlistener.com/opinion/4594866/wl-ives-md-v-bpoa-state-board-of-medicine/", "court": "State Board of Medicine, Commonwealth Court of Pennsylvania", "year": "2019", "quote": "Dr. Kauffman did not know that Dr. Ives transferred Patient’s care in the ICU to another physician only because he had been called to an emergency at another hospital.", "what_it_shows": "Why it matters here: transfer-of-care facts mattered, even outside nursing. If care was handed off, the record should say that plainly." } ], "guidance": [ { "says": "Patient abandonment is usually about accepting patient responsibility and then failing to continue care or transfer it. So document whether report or assignment was accepted, and who took over care.", "sources": [ { "name": "Minnesota Board of Nursing", "url": "https://mn.gov/boards/nursing/practice/nursing-practice-topics/patient-abandonment-faq.jsp" }, { "name": "Credenza", "url": "https://credenzahealth.com/career-advice/what-is-patient-abandonment-in-nursing" } ] }, { "says": "A missed shift before you accept an assignment should be charted as attendance and coverage. Not as a patient-care handoff.", "sources": [ { "name": "Minnesota Board of Nursing", "url": "https://mn.gov/boards/nursing/practice/nursing-practice-topics/patient-abandonment-faq.jsp" }, { "name": "Lento Law Firm", "url": "https://www.professionallicensedefensellc.com/are-you-a-nurse-accused-of-abandoning-your-patients" } ] }, { "says": "If you report to work and believe the assignment is unsafe before taking report, escalate right away. Ask for added staff or direction. Document the objective facts.", "sources": [ { "name": "New Hampshire Board of Nursing", "url": "https://www.oplc.nh.gov/sites/g/files/ehbemt441/files/inline-documents/sonh/abandonment.pdf" }, { "name": "Nurse Guidance", "url": "https://nurseguidance.com/abandonment-what-it-is-and-is-not/" } ] } ], "ready_to_copy": "[DATE] [TIME]\n\nI am scheduled for [UNIT] from [SHIFT START] to [SHIFT END]. I am unable to report for this shift due to [REASON]. I have not received report, accepted keys, accepted a patient assignment, or provided care for this shift.\n\nI notified [NAME/TITLE] by [PHONE/TEXT/EMAIL] at [TIME]. Please confirm receipt and coverage plan per unit process.\n\n[YOUR NAME], [CREDENTIAL]", "samples_are_written": true }, { "slug": "asking-for-time-off", "title": "Ask for the days you actually need and get the answer on paper", "search_title": "Requesting time off as a nurse: getting the answer in writing", "question": "How do I ask for time off so the answer is on paper?", "asked_as": "nurse request time off vacation denied policy PTO schedule", "cluster": "shift", "url": "https://shiftiswild.com/notes/asking-for-time-off/", "markdown_url": "https://shiftiswild.com/notes/asking-for-time-off.md", "summary": "PTO gets messy fast when the request is vague, only said out loud, or bigger than the time you really need. Keep it tight: exact dates, exact shifts, official system, and an approval or denial you can find later.", "key_points": [ "Put the request in the scheduling portal, HR system, or email. If you ask in person first, send a same-day written follow-up.", "Ask for the exact dates, exact shifts, and exact PTO hours. Don’t request the whole week if you only need three shifts covered.", "Keep the reason simple: PTO, vacation, personal day, bereavement, medical leave process, or whatever category your policy uses.", "Get the answer in writing: approved, denied, or pending.", "Save the confirmation, denial, screenshot, email thread, and final schedule." ], "one_thing": "Ask for the exact shifts you need off, and make the approval or denial live in the portal or email.", "what_goes_wrong": "The usual problem: it sounds clear in your head, but it does not land clearly on the schedule.\n\nNeed that week off can mean five calendar days, three 12-hour shifts, no call, no weekend, no overtime pickup, or all of it. If the calendar is tight, the scheduler may deny the whole block because one piece is not open. If the request was verbal, now everyone is trying to remember what was actually said.\n\nThe fix is not a longer story. It is a cleaner request: these dates, these shifts, these PTO hours. Answer in the system or by email.", "rewrites": [ { "situation": "", "before": "Need vacation the first week of August if possible.", "after": "Requesting PTO for 08/03/2026 0700-1930, 08/04/2026 0700-1930, and 08/05/2026 0700-1930 only. I am available to work 08/06/2026 and 08/07/2026 if scheduled. Please approve or deny in the scheduling system." }, { "situation": "", "before": "Can you not schedule me around my trip?", "after": "Requesting not to be scheduled from 06/12/2026 at 1900 through 06/16/2026 at 0730. PTO requested for scheduled shifts during that period only. I am not requesting PTO for 06/10, 06/11, 06/17, 06/18, 06/19, or 06/20." }, { "situation": "", "before": "I already asked you about this in the break room.", "after": "Following our conversation today at 1430, I am submitting this written PTO request for 09/14/2026 0700-1930 and 09/15/2026 0700-1930. Please confirm approval or denial by email or in the portal." }, { "situation": "", "before": "Use my PTO for whatever days I am off.", "after": "Please apply 24 PTO hours to the approved shifts on 10/21/2026 and 10/22/2026. Do not apply PTO to other days unless I submit a separate request." }, { "situation": "", "before": "The portal denied it. That is unfair.", "after": "The portal shows denied for my PTO request submitted 04/02/2026 at 0815 for 07/03/2026 1900-0730 and 07/04/2026 1900-0730. Please confirm the scheduling reason for the denial and whether 07/05/2026 1900-0730 or 07/06/2026 1900-0730 is available instead." }, { "situation": "", "before": "I need time off for personal stuff and I do not want to explain everything.", "after": "Request type: PTO/personal. Requesting 05/18/2026 0700-1930. No additional schedule changes requested. Please approve or deny in writing." } ], "words_to_avoid": [ { "wording": "Sometime", "why": "No date, no shift, no deadline", "instead": "08/03/2026 0700-1930" }, { "wording": "That week", "why": "Too broad if you only need certain shifts", "instead": "PTO for these shifts only" }, { "wording": "Around my trip", "why": "Does not tell the scheduler when you are unavailable", "instead": "Not available from [DATE] [TIME] through [DATE] [TIME]" }, { "wording": "Whatever days", "why": "Lets someone else decide how your PTO is used", "instead": "Apply [HOURS] PTO to [DATES] only" }, { "wording": "I told you", "why": "Turns the issue into memory versus memory", "instead": "Following our conversation on [DATE] at [TIME]" }, { "wording": "ASAP", "why": "No clear response date", "instead": "Please confirm by [DATE] at [TIME]" }, { "wording": "Personal reasons", "why": "Can invite unnecessary questions", "instead": "PTO/personal day, no further schedule changes requested" }, { "wording": "I am taking off", "why": "Sounds like notice, not a request", "instead": "Requesting PTO approval for [DATES/SHIFTS]" }, { "wording": "Denied again", "why": "Does not identify the request", "instead": "Portal shows denied for request submitted [DATE] at [TIME]" }, { "wording": "If you deny this", "why": "Starts the message in conflict mode", "instead": "If these dates are unavailable, please list available alternatives" } ], "cases": [ { "case": "Placide-Eugene v. Visiting Nurse Service", "url": "https://www.courtlistener.com/opinion/7311944/placide-eugene-v-visiting-nurse-service/", "court": "District Court, E.D. New York", "year": "2015", "quote": "", "what_it_shows": "The opinion discussed a registered nurse’s vacation request system and the dates requested, denied, and approved. “When a VNSNY nurse wishes to schedule a vacation, the nurse is required to submit a vacation request to a VNSNY computer system called Work Brain.”" }, { "case": "Consolmagno v. Hospital of St. Raphael School of Nurse Anesthesia", "url": "https://www.courtlistener.com/opinion/7310900/consolmagno-v-hospital-of-st-raphael-school-of-nurse-anesthesia/", "court": "District Court, D. Connecticut", "year": "2014", "quote": "", "what_it_shows": "The opinion discussed written handbook language about time-off benefits. “Other benefits provided to Program participants, as stated in the Student Handbook, included three weeks of vacation time and eight sick days during the seventeen-month clinical phase.”" } ], "guidance": [ { "says": "Use a system that leaves a record, such as an HR portal, timekeeping system, or email. If you start in person, follow up in writing the same day.", "sources": [ { "name": "thepaystubs.com", "url": "https://www.thepaystubs.com/blog/human-resources/time-off-request" }, { "name": "prepory.com", "url": "https://prepory.com/blog/how-to-ask-for-time-off-of-work/" } ] }, { "says": "Get the yes or no captured, not just spoken. Keep the signed form, portal confirmation, or email. Later, check that PTO was entered correctly in payroll or timekeeping.", "sources": [ { "name": "hrforhealth.com", "url": "https://hrforhealth.com/blog/time-off-request-guide" }, { "name": "thepaystubs.com", "url": "https://www.thepaystubs.com/blog/human-resources/time-off-request-email" } ] }, { "says": "If the time off is medical, keep the routine PTO message short. Use the proper medical-leave paperwork process, and ask for work-focused documentation with the needed dates, restrictions, and return information if known.", "sources": [ { "name": "clinemedicalgroup.com", "url": "https://www.clinemedicalgroup.com/post/the-best-approach-to-asking-your-doctor-for-time-off-documentation" }, { "name": "upcounsel.com", "url": "https://www.upcounsel.com/doctors-note-for-work-law" } ] } ], "ready_to_copy": "Subject: PTO request for [DATES]\n\nHi [MANAGER NAME],\n\nI am requesting PTO for the following date(s) and shift(s):\n\n[DATE] [SHIFT START]-[SHIFT END]\n[DATE] [SHIFT START]-[SHIFT END]\n[DATE] [SHIFT START]-[SHIFT END]\n\nTotal PTO hours requested: [HOURS]\n\nI am requesting these date(s) and shift(s) only. I am available to work on [DATES AVAILABLE] if scheduled.\n\nPlease approve or deny this request in [SYSTEM NAME] or by reply to this email.\n\nThank you,\n[NAME]\n[UNIT]\n[ROLE]", "samples_are_written": true }, { "slug": "family-leave", "title": "Family leave without leaving a hole in your record", "search_title": "FMLA for nurses: what to put in writing and what retaliation cases turn on", "question": "You need family leave. What has to be in writing, and what do you keep a copy of?", "asked_as": "nurse FMLA family leave paperwork denied retaliation what to document", "cluster": "shift", "url": "https://shiftiswild.com/notes/family-leave/", "markdown_url": "https://shiftiswild.com/notes/family-leave.md", "summary": "You need family leave. The unit still has to staff the shift. Those are two separate problems.\nYour part is the paper trail: the request, the dates, the route for forms, and the employer’s answer. Get it in writing.", "key_points": [ "Ask in writing early. Include the start date, expected end date, whether it is continuous or intermittent, and the leave category. Do not drop a diagnosis into a group text.", "Keep your own copy of every leave document: request, eligibility notice, certification request, certification submitted, upload or fax proof, approval or denial, timecard coding, recertification, and return-to-work note.", "Send medical details only through HR, the leave administrator, employee health, or the approved portal. Not in a patient chart. Not on a staffing board. Not in the unit group chat.", "For intermittent leave, track each use: date, shift hours missed, who you notified, time notified, and claim or case number.", "If your hospital changes ownership, vendors, portals, or policies, ask for the current written leave process. Save the answer." ], "one_thing": "If leave touches your attendance, put four things in writing: the request, the dates, the paperwork route, and the employer’s answer. Then keep your own copy.", "what_goes_wrong": "The usual mistake is treating family leave like a hallway conversation.\n\nYour manager may say it is fine. The charge nurse may get it. Staffing may know you are out. Then later, the attendance system shows a plain absence because the leave administrator never had a written request, the right certification, or a date that matches the shift.\n\nThat is where people get burned.\n\nThe break usually happens in one of four places:\n\n- The request was verbal, so nobody can prove when it was made.\n- The medical certification was sent, but there is no proof anyone received it.\n- The absence was called in, but nobody linked it to the approved intermittent leave case.\n- The approval stayed in work email, and the employee lost access during leave, transfer, resignation, or termination.\n\nYou are not writing a novel. You are making the record boring: date, time, what you asked for, where the paperwork went, who received it, and how the absence should be coded.", "rewrites": [ { "situation": "", "before": "First request to care for a parent", "after": "`I need FMLA. My mom is really sick and I cannot keep doing this schedule.`" }, { "situation": "", "before": "Maternity, birth, or bonding leave", "after": "`I will be out sometime in June for maternity leave. I will let you know.`" }, { "situation": "", "before": "Intermittent approved leave for one shift", "after": "`I am calling off FMLA today.`" }, { "situation": "", "before": "Paperwork sent to HR or leave vendor", "after": "`The doctor filled it out already.`" }, { "situation": "", "before": "Leave pending, not approved yet", "after": "`Do not count this against me. It should be covered.`" }, { "situation": "", "before": "Leaving midshift for approved intermittent leave", "after": "`Had to leave for family stuff. Sorry.`" }, { "situation": "", "before": "Patient chart or care note when staffing changes", "after": "`Patient care delayed because RN left on FMLA.`" }, { "situation": "", "before": "If an absence was coded wrong", "after": "`You messed up my timecard again.`" } ], "words_to_avoid": [ { "wording": "`Family emergency`", "why": "Too vague for leave paperwork", "instead": "`Family-care leave request for [DATE]`" }, { "wording": "`FMLA day`", "why": "Does not say if it is approved, pending, or just requested", "instead": "`Approved intermittent leave, case [NUMBER]` or `pending family leave request`" }, { "wording": "`My manager approved it`", "why": "Useful, but not enough if HR or the leave vendor has to designate it", "instead": "`Please confirm leave designation in writing`" }, { "wording": "`The doctor sent something`", "why": "No date, no route, no proof", "instead": "`Certification submitted on [DATE] by [PORTAL / FAX / EMAIL], confirmation [NUMBER]`" }, { "wording": "`Maternity leave sometime soon`", "why": "No start date or planning date", "instead": "`Estimated leave start [DATE]; estimated return or reevaluation [DATE]`" }, { "wording": "`Retaliation`", "why": "A conclusion, not a record of events", "instead": "`On [DATE], [ACTION] occurred after my leave request dated [DATE]. Please review the leave coding and attendance record.`" }, { "wording": "`They know what is going on`", "why": "The next person reading the file may not know", "instead": "`Leave administrator notified on [DATE] at [TIME]`" }, { "wording": "`Do not count this against me`", "why": "Does not identify the leave basis", "instead": "`Please code this absence to approved leave case [NUMBER]`" } ], "cases": [ { "case": "Matson v. Sanderson Farms, Inc.", "url": "https://www.courtlistener.com/opinion/7336633/matson-v-sanderson-farms-inc/", "court": "District Court, S.D. Texas", "year": "2019", "quote": "documents showing that Sanderson Farms granted Matson's FMLA leave", "what_it_shows": "The record included FMLA certifications, approval documents, return-to-work letters, and email. One item in the record was: Why you care: leave paperwork, provider letters, and email trails are not background noise. They become the timeline." }, { "case": "Linson v. Ohio Dept. of Rehab. & Corr.", "url": "https://www.courtlistener.com/opinion/9506404/linson-v-ohio-dept-of-rehab-corr/", "court": "Ohio Court of Claims", "year": "2024", "quote": "Plaintiff submitted all the appropriate Family Medical Leave Act (FMLA) paperwork when necessary and Defendant approved every request.", "what_it_shows": "This nurse’s leave history was part of the written record: Why you care: if you submit the paperwork and the employer approves it, keep that approval. People may need it later to piece together what happened." }, { "case": "Whitlow v. Visiting Nurse Ass'n of Western NY", "url": "https://www.courtlistener.com/opinion/2519987/whitlow-v-visiting-nurse-assn-of-western-ny/", "court": "District Court, W.D. New York", "year": "2005", "quote": "In a memorandum dated May 7, 2001, the VNA notified plaintiff that her request for intermittent FMLA leave had been approved, subject to medical re-certification every thirty days", "what_it_shows": "The record showed intermittent leave approval and recertification terms: Why you care: intermittent leave is not just the first approval. Recertification dates, restrictions, and follow-up notes belong in your file." }, { "case": "Alford v. Providence Hospital", "url": "https://www.courtlistener.com/opinion/8486465/alford-v-providence-hospital/", "court": "Court of Appeals for the D.C. Circuit", "year": "2014", "quote": "she exhausted her rights to leave under those statutes in April 2010", "what_it_shows": "The court focused on the leave timeline, including this point: Why you care: track the dates used, extensions granted, and what happened after leave ended." }, { "case": "Eldridge v. Hospital of Central Connecticut", "url": "https://www.courtlistener.com/opinion/10330056/eldridge-v-hospital-of-central-connecticut/", "court": "Connecticut Appellate Court", "year": "2025", "quote": "she had exhausted her FMLA leave as of August 6, 2018, and her CFMLA leave as of September 3, 2018", "what_it_shows": "The written leave timeline included specific exhaustion dates: Why you care: save return-to-work status, license status, exhaustion dates, and extension notices as separate documents." } ], "guidance": [ { "says": "Give written notice as early as you can when the leave is foreseeable. If you can plan ahead, aim for about 30 days before the start date.", "sources": [ { "name": "U.S. Department of Labor", "url": "https://www.dol.gov/agencies/whd/fmla" }, { "name": "Mass.gov", "url": "https://www.mass.gov/info-details/pfml-about-family-leave-to-care-for-a-family-member" } ] }, { "says": "Use the form or certification route that matches the reason for leave: your own condition, a family member’s condition, birth-related medical leave, bonding leave, or a state paid-leave claim.", "sources": [ { "name": "U.S. Department of Labor", "url": "https://www.dol.gov/agencies/whd/fmla/forms" }, { "name": "Washington Paid Family and Medical Leave", "url": "https://paidleave.wa.gov/get-ready-to-apply/" } ] }, { "says": "Be ready to upload or submit documents that verify the leave request. State paid-leave programs may have their own documents on top of your employer’s process.", "sources": [ { "name": "Mass.gov", "url": "https://www.mass.gov/info-details/required-documents-for-your-paid-family-and-medical-leave-pfml-application" }, { "name": "Washington Paid Family and Medical Leave", "url": "https://paidleave.wa.gov/get-ready-to-apply/" } ] }, { "says": "For intermittent leave, keep a shift-by-shift record of dates and hours used. Partial-day increments and gaps between leave days can matter.", "sources": [ { "name": "New York Paid Family Leave", "url": "https://paidfamilyleave.ny.gov/paid-family-leave-family-care" }, { "name": "HR Morning", "url": "https://www.hrmorning.com/articles/fmla-record-keeping-requirements-you-need-to-know/" } ] }, { "says": "Medical certifications and medical history belong in a confidential medical or leave file. Not in routine unit notes, staffing chatter, or a general personnel folder.", "sources": [ { "name": "DOL elaws", "url": "https://webapps.dol.gov/elaws/whd/fmla/8b6.aspx" }, { "name": "HR Morning", "url": "https://www.hrmorning.com/articles/fmla-record-keeping-requirements-you-need-to-know/" } ] } ], "ready_to_copy": "[DATE] [TIME]\n\nTo: [HR OR LEAVE ADMINISTRATOR NAME]\nCc: [MANAGER NAME]\n\nSubject: Family leave request for [YOUR NAME]\n\nI am requesting family leave beginning [DATE] for [REASON CATEGORY: CARE FOR FAMILY MEMBER / BONDING / MILITARY FAMILY LEAVE]. The leave requested is [CONTINUOUS / INTERMITTENT / REDUCED SCHEDULE].\n\nExpected schedule:\n- Start date: [DATE]\n- Estimated end date or reevaluation date: [DATE]\n- If intermittent: [EXPECTED FREQUENCY AND DURATION]\n\nPlease send the required eligibility notice, rights and responsibilities notice, certification instructions, and designation instructions to [EMAIL].\n\nI will submit required documentation through [PORTAL / FAX / HR EMAIL] by [DATE]. Please confirm in writing that this request was received and identify the claim or case number if one is assigned.\n\n[YOUR NAME]\n[TITLE / UNIT]\n[PHONE]", "samples_are_written": true }, { "slug": "named-in-suit", "title": "Your Name Is on the Lawsuit", "search_title": "Nurse named in a malpractice suit: what happens to your notes and what to do first", "question": "A patient sued. Your name is on it. What happens now, and what do your notes do?", "asked_as": "nurse named in lawsuit deposition subpoena my charting what happens", "cluster": "shift", "url": "https://shiftiswild.com/notes/named-in-suit/", "markdown_url": "https://shiftiswild.com/notes/named-in-suit.md", "summary": "A patient sues, and your name is in the paperwork because you were part of the care. That alone does not mean anyone has decided you did something wrong.\nBut now your charting gets read closely. By people who were not there. It becomes the timeline, the memory aid, and the record of what you assessed, did, reported, and followed up on.", "key_points": [ "Do not pretend to remember more than you remember. Keep your memory separate from what the chart says.", "Review the chart only through your facility’s approved process.", "Do not change old charting. If something truly needs to be added, use the approved late-entry or addendum process.", "Keep case talk inside the facility’s risk/legal process. Do not work it out in the hallway with coworkers.", "Good notes are not speeches. They show assessment, action, notification, response, and timing." ], "one_thing": "Two years later, your best memory aid is the chart. It needs to show what you saw, what you did, who you told, and how the patient responded.", "what_goes_wrong": "The usual mistake is trying to fix the chart after the lawsuit shows up.\n\nA nurse gets a letter, panics, opens an old encounter, and adds something like: provider aware, no distress, care appropriate. The problem is not about being a bad person. The problem is how it looks: the chart now reads like it was written for the lawsuit, not for patient care.\n\nEHRs show timing, authorship, edits, and addenda. A vague defensive note usually does not help anyone understand what happened.\n\nThe better move is boring. Preserve the original record. Use approved channels. If you find a true omission, label it as a late entry or addendum according to policy.\n\nThe chart should answer: What did you see? What did the patient say? What did you do? Who did you notify? What happened next?", "rewrites": [ { "situation": "", "before": "Patient fell. MD aware. Family notified.", "after": "0715 Patient found sitting on floor next to bed, back against bedside cabinet, non-skid socks on, call light on bed. Patient alert, states: I was trying to reach my water. Denies head strike. Vitals 0718: BP 138/76, HR 88, RR 18, SpO2 96 percent RA. Full skin check completed; 2 cm redness noted right elbow, no open area. Charge RN notified 0720. Provider [NAME] notified 0725; order received for neuro checks q4h x24h. Son [NAME] notified 0735." }, { "situation": "", "before": "Pt refused bath.", "after": "1430 Shower offered with stand-by assist. Patient declined and stated: I do not want a shower today. Offered basin bath and later shower time; patient declined both. Explained reason for hygiene and skin checks. Visible skin to arms, legs, and back intact. Feet not assessed because patient declined sock removal. Charge RN [NAME] notified 1445. Will re-offer hygiene care on evening rounds." }, { "situation": "", "before": "Med late due to pharmacy.", "after": "0900 Scheduled furosemide 40 mg PO not available in patient drawer or Pyxis. Pharmacy refill request sent 0903. Medication received 0947 and administered 0952. Patient denied shortness of breath before administration. BP 132/70, HR 82." }, { "situation": "", "before": "Patient confused.", "after": "1015 Patient awake, oriented to name only. States current year is 1998 and location is home. Attempted to get out of bed x2 without assistance between 1000 and 1015. Bed alarm on, low bed position, call light within reach. Reoriented patient to room and plan of care. Provider [NAME] notified 1020 of change from prior assessment of A&O x3 at 0700." }, { "situation": "", "before": "Wound looks bad. MD aware.", "after": "1605 Left heel wound assessed during dressing change. Open area 3.0 cm x 2.2 cm x 0.2 cm, wound bed 70 percent yellow slough and 30 percent pink tissue, scant serous drainage, no odor. Periwound skin macerated. Patient reports pain 6/10 during cleansing. Photo uploaded per policy. Provider [NAME] notified 1620; wound-care consult requested." }, { "situation": "", "before": "Family upset and blaming staff.", "after": "1810 Daughter [NAME] at bedside voiced concern that patient had not received bath today and asked when skin was last checked. Reviewed today’s offered shower and patient’s declination. Offered to re-approach patient with daughter present. Patient agreed to partial bath at 1825. Sacrum inspected with CNA [NAME]; skin intact, blanchable redness present. Barrier cream applied." }, { "situation": "", "before": "No new orders.", "after": "2215 Provider [NAME] notified by phone of temperature 101.4 F, HR 104, BP 118/64, RR 20, SpO2 95 percent RA, and patient report of chills. Provider gave order for acetaminophen 650 mg PO once and urine sample if patient voids. Order read back and entered. Acetaminophen given 2225." } ], "words_to_avoid": [ { "wording": "accidentally", "why": "Jumps to a conclusion you may not know", "instead": "Describe what happened and what you observed" }, { "wording": "mistake", "why": "Sounds like a legal conclusion, not an assessment", "instead": "Medication/time/event facts, notification, patient response" }, { "wording": "stable", "why": "Means almost nothing by itself", "instead": "Vitals, mental status, pain score, respiratory status, skin findings" }, { "wording": "MD aware", "why": "Does not show what you reported or what came back", "instead": "Provider [NAME] notified at [TIME] of [FACTS]; [ORDERS/NO ORDERS/PLAN]" }, { "wording": "refused", "why": "Can sound final or judgmental", "instead": "Declined after education; alternatives offered; patient response" }, { "wording": "combative", "why": "Labels the patient instead of charting behavior", "instead": "Kicking toward staff, pulling at IV, yelling, unable to redirect" }, { "wording": "noncompliant", "why": "Blames the patient and hides the useful details", "instead": "Missed dose, declined treatment, reason stated, education given" }, { "wording": "poor historian", "why": "A label. It does not chart the problem", "instead": "Patient unable to state date of surgery; answers inconsistent; family contacted for history" }, { "wording": "no issues", "why": "Tells the reader nothing", "instead": "Specific assessment findings" }, { "wording": "will continue to monitor", "why": "Vague unless you say what you are actually doing", "instead": "Neuro checks q4h, recheck BP in 30 min, reassess pain at [TIME]" } ], "cases": [ { "case": "Marvin Mead v. Charles Palmer", "url": "https://www.courtlistener.com/opinion/2820097/marvin-mead-v-charles-palmer/", "court": "Court of Appeals for the Eighth Circuit", "year": "2015", "quote": "The defendants’ appendix included transcripts of the depositions of Mead and dentist Timothy DeStigter; Mead’s dental records; and CCUSO documents, including Mead’s account statement, nursing notes, and a health-services request from Mead.", "what_it_shows": "A nurse was one of the named defendants, and the record included nursing notes and health-service requests" }, { "case": "Manter v. CPF Senior Living – Northgate Park L.L.C.", "url": "https://www.courtlistener.com/opinion/9492977/manter-v-cpf-senior-living-northgate-park-llc/", "court": "Ohio Court of Appeals", "year": "2024", "quote": "if Paul was noncompliant with bathing, that was something she would expect to see in the nursing notes.", "what_it_shows": "The case record discussed missing nursing notes and bathing documentation in an assisted-living care dispute" }, { "case": "Vanner v. Lakewood Quarters Retirement Community", "url": "https://www.courtlistener.com/opinion/4993800/vanner-v-lakewood-quarters-retirement-community/", "court": "Louisiana Court of Appeal", "year": "2013", "quote": "However the panel had concerns with the gap in nursing notes' from 5-7-06 to 5-11-06.", "what_it_shows": "A gap in nursing notes was called out in the malpractice record, even though the case also turned on other proof issues" }, { "case": "Schwenzfeier v. St. Peter's Health Partners", "url": "https://www.courtlistener.com/opinion/9376085/schwenzfeier-v-st-peters-health-partners/", "court": "Appellate Division of the Supreme Court of the State of New York", "year": "2023", "quote": "Although there was a discrepancy between the nursing notes and Price's observations of decedent during her initial consult", "what_it_shows": "Nursing notes were compared with provider observations during review of the patient’s hospital course" } ], "guidance": [ { "says": "Chart facts: assessment, patient statements, interventions, notifications, and response. Keep blame and self-defense out.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" }, { "name": "NursingCenter", "url": "https://www.nursingcenter.com/upload/Journals/Documents/200303nsoce3sued.htm" } ] }, { "says": "If you find an omission or error, use your facility’s late-entry or addendum process. Preserve the original record. Do not rewrite old charting.", "sources": [ { "name": "NursingCenter", "url": "https://www.nursingcenter.com/upload/journals/documents/200303nsoce3sued.htm" }, { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" } ] }, { "says": "Chart the care communication that matters: who you contacted, why, what you told them, what instructions or orders you received, and how the patient responded.", "sources": [ { "name": "PMC", "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC9183775/" }, { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" } ] }, { "says": "Make timing and authorship clear: date, time, author, credentials, and signature according to your system.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" }, { "name": "Berxi", "url": "https://www.berxi.com/resources/articles/nurse-charting-101/" } ] } ], "ready_to_copy": "[DATE] [TIME] Patient [WHAT HAPPENED]. Patient found/observed [POSITION/LOCATION/CONDITION]. Patient stated: [PATIENT WORDS]. Assessment completed: BP [BP], HR [HR], RR [RR], SpO2 [SPO2], temperature [TEMP], pain [PAIN SCORE/LOCATION], neuro status [NEURO STATUS], skin findings [SKIN FINDINGS]. Interventions completed: [INTERVENTIONS]. [NAME/TITLE] notified at [TIME] of [FACTS REPORTED]. Orders/instructions received: [ORDERS OR NO NEW ORDERS]. Patient response after intervention: [RESPONSE]. Family/representative [NAME] notified at [TIME], if applicable. Safety measures in place: [MEASURES].", "samples_are_written": true }, { "slug": "floating", "title": "Floated to a Unit You Do Not Know", "search_title": "Floating to another unit: what you can refuse and what to document", "question": "They floated you somewhere you have never worked. What do you say, and what do you write?", "asked_as": "nurse floated to another unit refuse assignment competency what to document", "cluster": "shift", "url": "https://shiftiswild.com/notes/floating/", "markdown_url": "https://shiftiswild.com/notes/floating.md", "summary": "You get sent to a unit you have never worked on. The assignment has patients, equipment, or tasks you have not been trained to handle. Do not make it a fight. Say the limit early, ask for a plan that works, and leave a clean record of what you said.", "key_points": [ "Say it before you accept or start work outside your training.", "Be specific. Name the task, equipment, drip, patient group, or monitoring you are not trained or validated for.", "Say what you can do: meds, assessments, vitals, turns, admissions, discharges, task help, stable patients, or paired care.", "Ask for a named resource nurse or a changed assignment.", "Document the facts: who you told, when, what limits you stated, what help you asked for, and what plan was made." ], "one_thing": "Name the specific task you cannot take on, who you told, what help you asked for, and what plan was made.", "what_goes_wrong": "The usual mistake is writing only: I am not comfortable here.\n\nThat may feel clear when you say it. It is not clear on paper. What is the problem? The charting system? Vents? Epidurals? Fresh trachs? Triage? Titrated drips? Pediatric dosing? If your note is vague, the next person has to guess.\n\nThe other mistake is writing the conclusion instead of what happened. Unsafe assignment is a conclusion. A useful note explains the reason: no orientation to the unit, no validation for the device or medication, no resource assigned, the assignment still included that task, and who you notified.", "rewrites": [ { "situation": "", "before": "Floated to ICU. Unsafe assignment.", "after": "1905 Floated from Med-Surg to ICU. Notified A. Patel, RN charge nurse, that I have not been trained or validated for ventilator management, titratable vasoactive drips, or invasive hemodynamic monitoring. Stated I can provide assessments, scheduled medications within Med-Surg competency, turns, hygiene, blood glucose checks, and documentation support. Requested ICU resource RN for ventilator and drip management. M. Lee, RN assigned as resource for rooms 12 and 14." }, { "situation": "", "before": "Refused vent patient.", "after": "1915 Assignment included room 12, intubated patient on mechanical ventilation. Informed A. Patel, RN charge nurse, that ventilator management is outside my current training and validation. Requested reassignment or ICU RN coverage for ventilator-related care. M. Lee, RN assumed ventilator management. I provided non-ventilator nursing care per assignment and notified M. Lee of respiratory alarms or changes." }, { "situation": "", "before": "I do not know this unit.", "after": "1845 Floated from Postpartum to ED. No prior ED orientation. Asked charge RN J. Green for location of code cart, medication room, clean supply, glucometer process, emergency call process, and assigned resource nurse. Unit walk-through completed with K. Brown, RN at 1855. Resource RN for shift: K. Brown, RN." }, { "situation": "", "before": "They forced me to take unsafe patients.", "after": "1900 Received assignment for rooms 3, 4, 7, and 8. Room 7 ordered insulin drip with hourly titration. Notified charge RN S. Nguyen that I have not been trained or validated for insulin drip titration on this unit. Requested drip be managed by unit-trained RN or patient reassigned. S. Nguyen assigned L. Carter, RN to titrate insulin drip and remain resource for room 7." }, { "situation": "", "before": "Med late because I was floated and nobody helped.", "after": "2130 Vancomycin due. Medication not available in unit Pyxis. Requested medication from pharmacy at 2135 and notified charge RN at 2140. Medication received at 2210 and administered at 2215 per MAR. Patient tolerated infusion without reaction." }, { "situation": "", "before": "I told them I was not comfortable, but they ignored me.", "after": "1850 Informed charge RN D. Smith that I have not previously worked on Pediatric Oncology and have no current chemotherapy validation. Assignment included room 22 with scheduled chemotherapy. Requested chemotherapy-certified RN for chemotherapy administration. D. Smith assigned R. Lopez, RN to administer chemotherapy. I provided non-chemotherapy care for room 22, including assessment, vitals, comfort measures, and parent teaching within current competency." } ], "words_to_avoid": [ { "wording": "Unsafe", "why": "Too broad. It does not explain the actual risk.", "instead": "Specific task or condition: ventilator management, titratable drip, fresh trach, epidural, triage" }, { "wording": "Refused", "why": "Makes it sound like you would not work at all.", "instead": "Stated outside current training and requested reassignment/resource" }, { "wording": "Not comfortable", "why": "Describes a feeling, not a competency limit.", "instead": "Not trained, not oriented, not validated for specific task" }, { "wording": "Forced", "why": "Argues about motive.", "instead": "Assigned by name after competency disclosure" }, { "wording": "Incompetent", "why": "Labels a person, including you.", "instead": "No documented training or validation for specific task" }, { "wording": "Not my unit", "why": "Does not explain how patient care is affected.", "instead": "Floated from home unit with no prior orientation to this unit" }, { "wording": "Nobody helped", "why": "Too vague.", "instead": "Resource requested from name at time; response was specific response" }, { "wording": "Short staffed", "why": "Usually not enough by itself.", "instead": "Assignment included number of patients, acuity, required monitoring, and available resource" }, { "wording": "Abandoned", "why": "A legal conclusion and loaded word.", "instead": "Notified charge, remained on unit, continued assigned care within competency" }, { "wording": "I cannot do this", "why": "Sounds global.", "instead": "I can do these tasks; I need resource or reassignment for these tasks" } ], "cases": [], "guidance": [ { "says": "Tell the charge nurse early if the float assignment includes care you are not trained or validated to do. Ask for a resource or a different plan before you take on that part of the assignment.", "sources": [ { "name": "RN Journal", "url": "https://rn-journal.com/journal-of-nursing/effects-of-floating-to-nurses-and-patient-care" }, { "name": "FRESHRN", "url": "https://www.freshrn.com/how-to-make-floating-not-suck/" } ] }, { "says": "Stay inside your current scope, training, and competency when you float. The unit changes. Your limits do not.", "sources": [ { "name": "Nursa", "url": "https://nursa.com/blog/travel-nurse-floating-policies" }, { "name": "Nursing Schools Near Me", "url": "https://nursingschoolsnearme.com/nurse-float-to-unfamiliar-unit/" } ] }, { "says": "Ask for the basics before you start: resource nurse, tip sheet, supply locations, charting expectations, emergency process, and who covers unfamiliar tasks.", "sources": [ { "name": "Whole Life Nurse", "url": "https://wholelifenurse.com/4-helpful-tips-to-help-you-survive-floating-to-another-unit/" }, { "name": "Passports and Preemies", "url": "https://www.passportsandpreemies.com/tips-for-nurses-who-have-to-float/" } ] }, { "says": "Make the documentation show what happened and what you did: times, notifications, care provided, and follow-up.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" }, { "name": "Nurse.Org", "url": "https://nurse.org/news/nursing-documentation-mistakes/" } ] } ], "ready_to_copy": "[TIME] [NAME], I was floated from [HOME UNIT] to [UNIT]. I have not worked on this unit before and have not been oriented to [SPECIFIC UNIT PROCESS/EQUIPMENT/PATIENT POPULATION].\n\nI can safely perform [TASKS YOU CAN DO]. I am not trained or validated to perform [TASKS YOU CANNOT DO].\n\nI can take an assignment limited to [PATIENT TYPE/TASKS]. I need [RESOURCE NAME/ROLE] for [TASKS NEEDING RESOURCE]. Please confirm my assignment and the resource nurse for this shift.", "samples_are_written": true }, { "slug": "unpaid-time", "title": "The break you didn’t get and the pay you didn’t see", "search_title": "Unpaid meal breaks and off-the-clock work for nurses: what records win", "question": "You worked through the break and clocked out on time. What proves it later?", "asked_as": "nurse missed meal break unpaid off the clock overtime how to prove", "cluster": "shift", "url": "https://shiftiswild.com/notes/unpaid-time/", "markdown_url": "https://shiftiswild.com/notes/unpaid-time.md", "summary": "You worked through lunch. Call lights, meds, report, another call light. Then you still clocked out on time.\nLater, the time system may show a clean unpaid meal break. Unless you left a clear record that you did not actually get one.", "key_points": [ "If you did not get an uninterrupted meal break, use the missed-meal, no-lunch, edit, or correction process before you leave. If you cannot do it safely then, do it as soon as you can.", "Write the exact window: scheduled break time, what interrupted it, what work you did, who you told, and when.", "Keep patient charting clinical. Pay and break facts belong in the timekeeping record, supervisor message, or approved facility form.", "Do not rely on memory, unit culture, or everyone knows we never get lunch. Later, the time clock and pay stub are usually the first things people look at.", "Do not keep patient names or PHI in personal notes. Use approved systems." ], "one_thing": "Patient chart shows care. Time record shows the pay issue. Make both true.", "what_goes_wrong": "The most common mistake is letting the computer tell the wrong story.\n\nHere is the mechanical problem: the timekeeping system may automatically deduct 30 minutes for lunch. If you clock out on time and do not submit a missed-meal correction, the record can look like you took a clean unpaid break.\n\nYour patient chart may show you were giving care around that time. It may not show that nobody relieved you. It may not show that the break was interrupted. It may not show that the meal deduction should be reversed, or that a charge nurse or manager knew about it.\n\nA patient note is not a pay record. A pay record is not a nursing note. You usually need both to be accurate.", "rewrites": [ { "situation": "", "before": "No lunch.", "after": "Missed meal correction: scheduled meal period 1230–1300 not taken. Remained responsible for Rooms 421, 423, and 424 due no relief nurse available. Gave scheduled meds, answered call lights, and took provider call during that time. Charge RN M. Lee notified at 1228 and 1306." }, { "situation": "", "before": "Too busy to take break.", "after": "Meal break interrupted at 1242 when Room 418 bed alarm sounded. Returned to patient care from 1242–1310. Assisted patient back to bed, completed fall-risk reassessment, notified charge RN at 1312. Uninterrupted 30-minute meal period not received." }, { "situation": "", "before": "Charted late.", "after": "Time correction request: clocked out at 1930, but required handoff and nursing documentation continued until 1956. Handoff for Rooms 410, 412, and 414 completed 1930–1944. MAR reconciliation and nursing notes completed 1944–1956. Charge RN notified at 1957." }, { "situation": "", "before": "Lunch missed, everyone knows staffing was bad.", "after": "Scheduled meal 0100–0130 not taken. Requested coverage from charge RN at 0055 and 0115. No relief nurse available. Continued assigned patient care, including 0100 neuro check, IV pump alarm response, and PRN pain medication administration. Missed-meal edit submitted at 0645." }, { "situation": "", "before": "Patient was needy, no break.", "after": "Patient record: 1251 patient reported shortness of breath. SpO2 89% on 2 L NC. Head of bed elevated, oxygen increased per protocol, respiratory therapy and provider notified. SpO2 improved to 94% at 1302. Patient resting, call light within reach." }, { "situation": "", "before": "I worked through lunch but clocked out on time.", "after": "Timekeeping note: unpaid meal deduction should be removed for 0700–1930 shift on 04/18. Meal period 1230–1300 was not uninterrupted. I remained on duty and performed patient care throughout the deducted period. Actual clock-out was 1930; missed-meal correction submitted same day." } ], "words_to_avoid": [ { "wording": "No lunch", "why": "Too vague; does not show whether the break was missed, shortened, or interrupted", "instead": "Uninterrupted meal period not taken from [TIME] to [TIME]" }, { "wording": "Busy", "why": "Explains nothing by itself", "instead": "No relief available after request to [NAME] at [TIME]" }, { "wording": "Skipped lunch", "why": "Can sound like a personal choice", "instead": "Requested coverage; remained assigned to patient care until [TIME]" }, { "wording": "Clocked out but charted", "why": "Missing actual work stop time and correction request", "instead": "Clocked out at [TIME]; continued required documentation until [TIME]; time correction submitted" }, { "wording": "Everyone knows", "why": "Does not identify notice", "instead": "[NAME/TITLE] notified at [TIME] by [METHOD]" }, { "wording": "Interrupted", "why": "Too general", "instead": "Break interrupted at [TIME] by [EVENT/TASK]; returned to break at [TIME] or did not resume break" }, { "wording": "Staffing unsafe", "why": "A conclusion without the facts", "instead": "Assigned to [NUMBER] patients; no relief nurse available; charge RN notified at [TIME]" }, { "wording": "Management made me", "why": "Sounds argumentative unless tied to facts", "instead": "[NAME/TITLE] instructed staff to clock out by [TIME]; I continued [TASK] until [TIME]" } ], "cases": [ { "case": "**David v. Queen of the Valley Medical Center**", "url": "https://www.courtlistener.com/opinion/4764840/david-v-queen-of-the-valley-medical-center/", "court": "California Court of Appeal", "year": "2020", "quote": "", "what_it_shows": "A registered nurse brought meal, rest, off-the-clock charting, and rounding claims. The court affirmed summary judgment for the hospital. The opinion describes the hospital’s missed-break process this way: “An employee who misses a meal or rest period must complete an “edit” or “correction” sheet, so QVMC can pay the employee a one-hour premium.”" }, { "case": "**Myers v. Marietta Memorial Hospital**", "url": "https://www.courtlistener.com/opinion/7321586/myers-v-marietta-memorial-hospital/", "court": "District Court, S.D. Ohio", "year": "2016", "quote": "", "what_it_shows": "Nurses challenged an automatic meal deduction policy. The court granted conditional collective action certification early in the FLSA case. One affidavit statement in the opinion said: “I do not recall a single day in the last three years when I was able to take a full 30-minute meal break free from all my job duties.”" }, { "case": "**Arkansas Department of Veterans Affairs v. Okeke**", "url": "https://www.courtlistener.com/opinion/2809801/arkansas-department-of-veterans-affairs-v-okeke/", "court": "Arkansas Supreme Court", "year": "2015", "quote": "", "what_it_shows": "RNs, LPNs, and CNAs brought claims involving meal-break auto-deductions and off-the-clock work. The court affirmed class certification and did not decide the merits. The opinion describes the allegation that “ADVA automatically deducted thirty minutes per day from their hours worked to account for lunch breaks”." }, { "case": "**Brady v. Autozone Stores, Inc.**", "url": "https://www.courtlistener.com/opinion/4404909/brady-v-autozone-stores-inc/", "court": "Washington Supreme Court", "year": "2017", "quote": "", "what_it_shows": "This was not a nursing case, but it shows why the record matters when a meal break is missed. The court answered certified questions about meal breaks and wrote: “The employer is not automatically liable if a meal break is missed because the employee may waive the meal break.”" } ], "guidance": [ { "says": "Make the time record match what happened: missed meal period, actual work time, correction request, and the work you did during the deducted period.", "sources": [ { "name": "PLBH", "url": "https://www.plblaw.com/documenting-wage-hour-violations-for-nurses-required-to-work-through-unpaid-meal-breaks/" }, { "name": "ShiftFlow", "url": "https://www.shiftflow.app/blog/healthcare-shift-handoff-time" } ] }, { "says": "Keep clinical charting focused on patient care. Make it match the care actually provided. Do not use the patient chart as your main payroll record.", "sources": [ { "name": "CareerStaff", "url": "https://www.careerstaff.com/clinician-life-blog/nursing/charting-in-nursing-dos-and-donts/" }, { "name": "Nurse.org", "url": "https://nurse.org/news/nursing-documentation-mistakes/" } ] } ], "ready_to_copy": "[DATE] [TIME]\n\nMissed meal period/time correction request.\n\nMy scheduled unpaid meal period was [START TIME]–[END TIME]. I did not receive an uninterrupted 30-minute meal period. During that time I remained responsible for [ASSIGNMENT/ROOMS] and performed [PATIENT CARE TASKS].\n\nI requested relief from [NAME/TITLE] at [TIME]. Relief was [NOT AVAILABLE/INTERRUPTED AT TIME]. I notified [CHARGE RN/MANAGER NAME] at [TIME] by [METHOD].\n\nI clocked out at [CLOCK-OUT TIME]. Actual work related to this shift ended at [ACTUAL END TIME].\n\nPlease correct the time record to reflect the missed meal period and actual work time.\n\n[NAME], [TITLE]", "samples_are_written": true }, { "slug": "written-up", "title": "When the Write Up Lands on You", "search_title": "Nurse corrective action and write-ups: what to sign, what to add, what to keep", "question": "You are being written up. What do you sign, what do you add, and what do you keep?", "asked_as": "nurse write up corrective action sign disagree rebuttal what to do", "cluster": "shift", "url": "https://shiftiswild.com/notes/written-up/", "markdown_url": "https://shiftiswild.com/notes/written-up.md", "summary": "A write-up can feel like an accusation. Let it. Your paperwork still needs to stay dull.\nKeep three things separate: the personnel form, the patient chart, and your own clean file with no PHI.", "key_points": [ "Read the form before you sign it. Ask what your signature means: receipt, attendance, agreement, or acceptance of the corrective action.", "If you sign, add a short receipt-only note if there’s room: received on [DATE] at [TIME]; written response attached or to follow.", "Don’t argue in the patient chart. Add to the chart only when patient-care information is missing, late, or wrong. Follow your facility’s late-entry or addendum policy.", "Write a factual response: what statement you disagree with, what happened, what policy or education applies, and what you’re willing to do next.", "Keep a copy of the write-up, your response, the relevant policy, emails, schedule, assignment records, and education records. Don’t keep screenshots, EHR printouts, MARs, incident reports, or patient identifiers in a personal file." ], "one_thing": "Sign only for receipt if that’s what you mean. Answer with facts. Keep the patient chart about the patient.", "what_goes_wrong": "The usual mistake: trying to win the whole fight in the wrong record.\n\nIf you write an emotional rebuttal on the form, your file now has the manager’s allegation and your frustrated tone sitting together. Not helpful.\n\nIf you put the workplace dispute in the medical record, the chart stops looking like a patient-care record. It starts looking like an argument at work.\n\nIf you refuse to sign without asking what the signature means, the form may still go into your file. Then there may be another note saying you refused to acknowledge it.\n\nKeep it mechanical. Sign only for what you mean to sign. Attach a factual response. Keep the patient chart about the patient.", "rewrites": [ { "situation": "", "before": "HAPI was not my fault. Day shift did not turn the patient and now management is blaming me.", "after": "Patient chart: 1930 sacral skin assessed during repositioning with PCT Maria Lopez. 2 cm x 1.5 cm nonblanchable erythema noted over coccyx; skin intact; no drainage. Barrier cream applied. Patient repositioned to left lateral with pillows; heels offloaded. Charge RN Kelly Martin notified at 1938. Wound consult request entered per unit process." }, { "situation": "", "before": "I gave the med. The scanner was broken. I am being written up for nothing.", "after": "Patient chart: 2204 oxycodone 5 mg PO administered for incisional pain 7/10 after two patient identifiers verified. Barcode scanner unavailable; downtime medication process used per policy. MAR updated at 2220 when workstation access restored. Pain reassessed at 2305: 3/10. Charge RN notified of scanner issue at 2200." }, { "situation": "", "before": "Charge nurse told me to change my note, but my charting stands.", "after": "HR response or email, not the patient chart: On 03/18 at 1645, I was asked to review my 1200 assessment note for accuracy. I reviewed the note at 1700. The documented assessment matched my findings at that time. I did not enter an addendum because I had no additional patient-care information to add." }, { "situation": "", "before": "Patient refused care all day.", "after": "Patient chart: 1000 patient declined repositioning and hygiene care, stating no, not now. Education provided on skin protection and comfort. Call light within reach. 1030 patient accepted partial bath and repositioning to right lateral. Skin intact on visualized areas." }, { "situation": "", "before": "Provider never responds. Unsafe situation.", "after": "Patient chart: 1415 BP 86/48, HR 118, patient pale and diaphoretic. Repeat BP 84/46 at 1418. Rapid response activated at 1419. Charge RN at bedside 1420. Provider paged at 1420 and returned call at 1423; orders received for 500 mL NS bolus and STAT CBC/BMP." }, { "situation": "", "before": "I disagree with this corrective action because everyone does it this way.", "after": "Written response: I disagree with the statement that I failed to notify the provider. The chart reflects provider notification at 1420 and return call at 1423. I agree to complete refresher education on escalation documentation by 03/25 and request clarification of the expected documentation location for provider notification." } ], "words_to_avoid": [ { "wording": "Lied", "why": "States intent you may not be able to prove", "instead": "The entry does not match my assessment at [TIME]" }, { "wording": "Falsified", "why": "Serious accusation; use only through the proper reporting channel", "instead": "I did not make that entry; my assessment was [FINDING]" }, { "wording": "Negligent", "why": "Legal conclusion, not a nursing observation", "instead": "[CARE] was not documented; [CARE] was completed at [TIME]" }, { "wording": "Abandoned", "why": "Legal label", "instead": "I notified [NAME/ROLE] at [TIME] before leaving the unit; coverage was assigned to [NAME]" }, { "wording": "Unsafe", "why": "Too broad by itself", "instead": "RN-to-patient assignment was [RATIO]; [TASK/CHANGE] was pending; charge RN notified at [TIME]" }, { "wording": "Refused", "why": "Can sound final or blaming", "instead": "Declined at [TIME]; education provided; reoffered at [TIME]" }, { "wording": "Noncompliant", "why": "Judgmental and vague", "instead": "Did not take [MEDICATION] at [TIME]; stated reason: [REASON]" }, { "wording": "Always or never", "why": "Easy to disprove with one exception", "instead": "On [DATE] at [TIME]" }, { "wording": "Incident report filed", "why": "The chart should not become an incident-report index", "instead": "Charge RN notified; provider notified; patient assessed; interventions completed" }, { "wording": "Management is retaliating", "why": "A personnel claim, not a patient-care fact", "instead": "I reported [EVENT] to [NAME] on [DATE]; I disagree with the stated basis for this corrective action" } ], "cases": [ { "case": "Nurse v. Lutheran Medical Center", "url": "https://www.courtlistener.com/opinion/8714492/nurse-v-lutheran-medical-center/", "court": "District Court, E.D. New York", "year": "2012", "quote": "", "what_it_shows": "The court described a workplace dispute where written accounts became part of the record: “Both plaintiff and Ms. Garcia wrote to Ms. Schwimer, Ms. Daisley, and others relaying their version of the events.”" }, { "case": "Straw v. Visiting Nurse Association and Hospice of VT/NH", "url": "https://www.courtlistener.com/opinion/1085850/straw-v-visiting-nurse-association-and-hospice-of-/", "court": "Supreme Court of Vermont", "year": "2013", "quote": "", "what_it_shows": "The nurse’s recollection and clinical records were part of the employment dispute background: “Plaintiff sent an email with her recollection of the case based on her log and progress notes.”" }, { "case": "Primes v. State Board of Practical Nurse Examiners", "url": "https://www.courtlistener.com/opinion/1644297/primes-v-state-bd-of-pract-nurse-examin/", "court": "Louisiana Court of Appeal", "year": "2008", "quote": "", "what_it_shows": "A facility report became part of a board matter: “The complaint arose from a report that Lakeview Medical Center (Lakeview) referred to the Board.”" } ], "guidance": [ { "says": "Build the patient note around assessment, care provided, teaching, and patient response. Not the employment dispute.", "sources": [ { "name": "Missouri Department of Health and Senior Services", "url": "https://health.mo.gov/living/lpha/phnursing/documentation.php" }, { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" } ] }, { "says": "Include the date, time, and clear author identification. The reader needs to know who documented what and when.", "sources": [ { "name": "Berxi", "url": "https://www.berxi.com/resources/articles/nurse-charting-101/" }, { "name": "Maryville Nursing", "url": "https://nursing.maryville.edu/blog/medical-documenting-5-important-things-to-remember" } ] }, { "says": "Keep entries accurate and consistent with facility and state expectations. If you need to correct something or add to it, use the approved process.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" }, { "name": "Nursing CE Central", "url": "https://nursingcecentral.com/lessons/nursing-documentation-101-how-to-guard-your-license/" } ] }, { "says": "Chart carefully and as close to the event as you reasonably can. Rushed notes and late notes are easier to leave incomplete.", "sources": [ { "name": "NSO", "url": "https://www.nso.com/Learning/Artifacts/Articles/Do-s-and-Don-ts-of-Documentation" }, { "name": "Joyce University", "url": "https://www.joyce.edu/blog/nurse-charting-and-documenting/" } ] } ], "ready_to_copy": "Received by [YOUR NAME], [TITLE], on [DATE] at [TIME].\n\nMy signature acknowledges receipt of this document and attendance at the meeting. My signature does not mean I agree with all statements in the document.\n\nWritten response attached or to follow by [DATE].\n\n[YOUR NAME], [TITLE]\n[DATE]\n[TIME]", "samples_are_written": true }, { "slug": "witness-stmt", "title": "When Risk Management Asks You for a Written Statement", "search_title": "Writing a statement for a hospital investigation: what belongs in it", "question": "Risk management wants your statement in writing. What belongs in it and what does not?", "asked_as": "nurse asked to write statement investigation incident what to include", "cluster": "shift", "url": "https://shiftiswild.com/notes/witness-stmt/", "markdown_url": "https://shiftiswild.com/notes/witness-stmt.md", "summary": "Risk Management may ask you for a written statement after a fall, medication issue, resident complaint, restraint event, transfer injury, or anything else that needs review.\nDo not turn it into a novel. Do not try to fix the whole event in one paragraph. Your job is simpler: write what you personally know, what someone told you, and what you did.", "key_points": [ "Start with your name, role, assignment, date, time, and whether you saw the event.", "Use a timeline: what you saw, what the patient said, what you assessed, what you did, and who you notified.", "If you got the information from someone else, name that person. If you did not see it, say that.", "Leave out blame, guesses, motives, policy conclusions, and comments about a coworker’s character.", "Keep the chart about patient care. Use the facility’s internal process for incident reports or risk statements." ], "one_thing": "Keep the lanes separate: what you saw, what you were told, and what you did.", "what_goes_wrong": "The usual mistake is trying to help by filling in the blanks.\n\nSay a nurse did not see the fall but writes that the patient fell because the bed was high and no one answered the call light. Now three things are mixed together: the event, a room condition, and a guessed cause. Later, nobody can tell what the nurse saw, what the patient said, what another staff member reported, and what the nurse assumed.\n\nA clean statement keeps those lanes separate:\n\n- What I personally observed\n- What the patient or resident said\n- What I was told, and by whom\n- What I assessed\n- What I did next\n- What I did not witness\n\nThat is not being defensive. It is good documentation.", "rewrites": [ { "situation": "", "before": "Resident fell from bed because the bed was too high.", "after": "0618 Entered room 214 after call light sounded. Resident found sitting on floor on left side of bed with back against nightstand. Bed observed in high position with brakes locked. Resident awake and answering questions. Resident stated: tried to go to bathroom. No bleeding observed. VS 132/78, HR 88, RR 18, SpO2 96% on room air. Charge RN and provider notified." }, { "situation": "", "before": "Nurse Smith dropped the patient during transfer.", "after": "I did not observe the transfer. At 1435 CNA [NAME] notified me that patient was on the bathroom floor. At 1437 I entered bathroom and observed patient seated on floor near toilet, gait belt around waist, wheelchair positioned at sink. Patient denied head strike. Skin check completed with no open areas noted. Charge RN notified at 1440." }, { "situation": "", "before": "Night shift neglected the patient and never turned him.", "after": "0705 Initial assessment completed. Patient supine in bed. Sacral dressing dated [DATE] intact with 2 cm serosanguineous drainage visible on dressing. Turn sheet showed last documented repositioning at 0200. Patient repositioned to left side with pillows at 0715. Skin warm and dry. Wound nurse notified per unit process." }, { "situation": "", "before": "The medication error happened because pharmacy was late.", "after": "Cefazolin dose due at 0900. Medication not available in Pyxis at 0855. Pharmacy message sent at 0856. Medication delivered to unit at 0940 and administered at 0945. Provider notified at 0950 of delayed dose. Patient remained afebrile at 1000." }, { "situation": "", "before": "Patient is lying about being hit.", "after": "Patient stated: night staff hit my arm. Patient alert and oriented to person, place, and time during statement. Left forearm assessed. 2 cm purple discoloration noted on posterior forearm; skin intact. Charge RN notified at 0810. Patient remained in room with call light within reach." }, { "situation": "", "before": "I did everything correctly and the fall was not my fault.", "after": "1900-2300 assigned to rooms 401-408. Last rounded on room 406 at 2145. Patient in bed, bed low, bed alarm on and audible, call light on chest. At 2210 bed alarm sounded. Entered room at 2211 and found patient standing beside bed holding walker. Assisted patient to chair with second staff member." }, { "situation": "", "before": "Incident report completed because staff were negligent.", "after": "Post-event assessment completed at 1805. Pupils equal and reactive. Hand grips equal. Patient denied headache, dizziness, nausea, or pain. Provider [NAME] notified at 1810. New orders: neuro checks q4h x 24 hours. Family contact [NAME] notified at 1820 per patient request." } ], "words_to_avoid": [ { "wording": "Fell", "why": "If you did not see the fall, it states more than you know.", "instead": "Found on floor. Patient reported fall. CNA reported patient on floor." }, { "wording": "Negligent", "why": "It is a conclusion, not an observation.", "instead": "Describe the action or condition you observed." }, { "wording": "Abuse or neglect", "why": "These may be required terms in reports, but do not use them as shortcuts for facts.", "instead": "Patient stated: [WORDS]. Observed: [FINDINGS]. Reported to: [NAME/TITLE]." }, { "wording": "Noncompliant", "why": "It sounds like a judgment.", "instead": "Declined medication. Removed oxygen tubing. Did not use call light before standing." }, { "wording": "Combative", "why": "It can be vague.", "instead": "Swinging right arm toward staff. Kicking legs toward footboard. Attempted to bite during care." }, { "wording": "Probably, must have, I think", "why": "These mark a guess.", "instead": "I did not observe. Source was [NAME/TITLE]." }, { "wording": "Always or never", "why": "Absolutes are easy to challenge and usually unnecessary.", "instead": "On [DATE] at [TIME]. During this shift. In the records reviewed at [TIME]." }, { "wording": "Short staffed caused this", "why": "It jumps to cause.", "instead": "Assignment was rooms [ROOMS]. At [TIME], call lights active in rooms [ROOMS]. Supervisor notified at [TIME]." }, { "wording": "Incident report completed", "why": "It does not describe patient care.", "instead": "Document assessment, interventions, notifications, orders, and patient response." }, { "wording": "My fault or not my fault", "why": "It turns the statement into self-defense.", "instead": "State the timeline and your actions." } ], "cases": [ { "case": "Cranford v. Louisiana State Board of Practical Nurse Examiners", "url": "https://www.courtlistener.com/opinion/7851618/cranford-v-louisiana-state-board-of-practical-nurse-examiners/", "court": "Louisiana Court of Appeal", "year": "2008", "quote": "L.P.N. Stacey Lowery made a formal written statement against Ms. Cranford, on the basis of which Ms. Ainsworth conducted an investigation.", "what_it_shows": "The opinion describes a facility investigation with a written statement, interviews, a facility report, the nurse’s written narrative, and objective information such as a blood glucose reading. The Board revoked the LPN license. The appellate court affirmed the trial court’s decision upholding the Board." }, { "case": "Primes v. STATE BD. OF PRACT. NURSE EXAMIN.", "url": "https://www.courtlistener.com/opinion/1644297/primes-v-state-bd-of-pract-nurse-examin/", "court": "Louisiana Court of Appeal", "year": "2008", "quote": "January 4, 2000: Mr. Primes was given a written warning for signing that he performed accuchecks, blood cultures, and administered antibiotics when he had not done so.", "what_it_shows": "The opinion listed documentation-related allegations. It also noted that, for some older allegations, the record did not contain testimony or other evidence at the Board hearing. The appellate court affirmed the trial court’s reversal of the Board order." }, { "case": "Shahnaz Poursaied v. Tennessee Board of Nursing", "url": "https://www.courtlistener.com/opinion/5289876/shahnaz-poursaied-v-tennessee-board-of-nursing/", "court": "Court of Appeals of Tennessee", "year": "2021", "quote": "The Department proceeded by introducing into evidence a certified copy of the CA Board’s administrative order revoking Ms. Poursaied’s California registered nurse license, an unsworn written statement from Ms. Poursaied to her travel nurse agency defending herself against the California charges, and affidavits from two administrative directors for the Board.", "what_it_shows": "The Tennessee court affirmed the chancery court in a reciprocal license discipline case. The written statement to the travel nurse agency was one of the materials introduced in the administrative proceeding." } ], "guidance": [ { "says": "Treat the patient chart as a formal patient-care and legal record. Keep internal risk-report language in the facility’s process, not mixed into progress notes.", "sources": [ { "name": "NursingCenter", "url": "https://www.nursingcenter.com/upload/journals/documents/legalethicalissues.html" }, { "name": "American Nurse", "url": "https://www.myamericannurse.com/nurse-spotlight-healthcare-documentation/" } ] }, { "says": "Write what you observed and what happened. Skip opinions and labels.", "sources": [ { "name": "NURSING.com", "url": "https://academy.nursing.com/lesson/01-02-daily-charting/" }, { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" } ] }, { "says": "Include the nursing process: assessment findings, interventions, follow-up, and what you did to reduce risk.", "sources": [ { "name": "OpenStax", "url": "https://openstax.org/books/fundamentals-nursing/pages/14-5-guidelines-for-effective-documentation" }, { "name": "Ohio Nurses Association", "url": "https://ohnurses.org/documentation-101-what-every-nurse-needs-to-know-to-help-avoid-liability-risks/" } ] }, { "says": "Keep entries clear, relevant, accurate, and short enough that another clinician can understand them later.", "sources": [ { "name": "RNpedia", "url": "https://www.rnpedia.com/nursing-notes/fundamentals-in-nursing-notes/charting/" }, { "name": "CareerStaff", "url": "https://www.careerstaff.com/clinician-life-blog/nursing/charting-in-nursing-dos-and-donts/" } ] }, { "says": "Do not use unsafe or unclear abbreviations and shorthand.", "sources": [ { "name": "American Nurse", "url": "https://www.myamericannurse.com/dos-and-donts-of-defensive-documentation/" }, { "name": "CareerStaff", "url": "https://www.careerstaff.com/clinician-life-blog/nursing/charting-in-nursing-dos-and-donts/" } ] } ], "ready_to_copy": "[DATE] [TIME]\n\nI am [NAME], [CREDENTIAL], assigned to [UNIT/ROOMS] from [START TIME] to [END TIME] on [DATE].\n\nThis statement concerns [PATIENT/RESIDENT IDENTIFIER] and [EVENT].\n\nAt [TIME], I personally observed [WHAT YOU SAW OR HEARD]. The patient/resident was [POSITION/LOCATION/CONDITION]. Environmental observations at that time: [BED POSITION, CALL LIGHT LOCATION, ALARM STATUS, EQUIPMENT, FLOOR CONDITION, OR NOT APPLICABLE].\n\nPatient/resident statement: [PATIENT WORDS OR NOT APPLICABLE].\n\nAssessment findings: [ASSESSMENT FINDINGS, INCLUDING VITAL SIGNS IF OBTAINED].\n\nInterventions completed: [INTERVENTIONS].\n\nNotifications: [NAME/TITLE] notified at [TIME]. Orders or instructions received: [ORDERS/INSTRUCTIONS OR NONE].\n\nFollow-up: [PATIENT RESPONSE/STATUS AFTER INTERVENTIONS].\n\nI did not observe [ANY PART OF THE EVENT YOU DID NOT SEE OR NOT APPLICABLE].\n\nThis statement is based on my personal observations and actions unless a source is named above.\n\n[NAME], [CREDENTIAL]\n[DATE] [TIME]", "samples_are_written": true }, { "slug": "telling-boss", "title": "How to Tell Work You Are Leaving", "search_title": "Resigning as a nurse: notice, what to put in writing, what happens after", "question": "You are leaving. What do you say, what do you put in writing, and what happens after?", "asked_as": "nurse resignation two weeks notice what to say manager leaving job", "cluster": "shift", "url": "https://shiftiswild.com/notes/telling-boss/", "markdown_url": "https://shiftiswild.com/notes/telling-boss.md", "summary": "Leaving a nursing job does not need a big scene. Tell your manager, put the same facts in writing, then chart like you always do until your last shift is over. Don’t turn a resignation into a speech, a complaint letter, or a patient note.", "key_points": [ "Tell your manager directly if you can. Then send the same facts in writing to your manager and HR.", "Put the basics in the notice: your role, your unit, that you are resigning, and your last available work shift.", "Keep the reason short. Or leave it out. Your notice is not where you unpack every bad shift.", "After you give notice, confirm your final schedule, HR steps, badge or equipment return, and whether any shifts changed.", "Keep patient charting normal: objective, timed, patient-focused, and free of resignation drama." ], "one_thing": "Put the resignation in the manager or HR message. Keep the patient chart about the patient.", "what_goes_wrong": "The usual mistake is mixing two records that need to stay separate: your employment notice and the patient chart.\n\nYour resignation notice is for your manager and HR. It answers a scheduling question: when are you leaving, and what shifts can you still work? If the message is long, emotional, or unclear, the useful facts get buried.\n\nThe patient chart is for patient care. Do not chart why you are quitting, how frustrated you are with staffing, or what you think about management. If there is a patient-care concern, document the facts: time, patient condition, what you did, who you notified, and what happened next.\n\nAfter you resign, the facility may accept the notice, keep your remaining shifts, shorten the schedule, ask about PRN status, or send HR paperwork. Get the final work date in writing. Then keep working and charting normally unless your schedule is changed.", "rewrites": [ { "situation": "", "before": "I am done with this place. This unit is toxic and management has ignored us. I guess my last day is two weeks from now.", "after": "Effective [DATE], I am resigning from my position as RN on [UNIT]. My last available work shift will be [DATE], [TIME] to [TIME]." }, { "situation": "", "before": "I cannot work here anymore because staffing is dangerous.", "after": "I am resigning from my position as [TITLE] on [UNIT]. My last available work shift will be [DATE], [TIME] to [TIME]. I will work my posted shifts through that date unless the schedule is changed." }, { "situation": "", "before": "If you do not fix my schedule, I am leaving today.", "after": "I am available for my scheduled shifts on [DATES]. I am not available for additional shifts after [DATE]." }, { "situation": "", "before": "Keep me PRN if possible, but if not, whatever.", "after": "I am resigning from my [FULL-TIME/PART-TIME] position on [UNIT]. If a PRN role is available after [DATE], I would like to be considered." }, { "situation": "", "before": "Patient note: Short staffed again. This is why I resigned.", "after": "Patient note: [TIME] RN assigned patients [ROOMS]. Patient [ROOM] requested pain medication at [TIME]. Assessment completed. [MEDICATION] administered per MAR at [TIME]. Pain reassessed at [TIME], [SCORE]/10. Charge RN [NAME] notified at [TIME] that assistance was needed for [TASK]." }, { "situation": "", "before": "Patient note: I am leaving at 1900 and somebody needs to deal with this mess.", "after": "Handoff note: Report given to [NAME], RN at [TIME]. Reviewed current condition, IV site [LOCATION/STATUS], medications due at [TIME], pending [LAB/CONSULT], fall precautions, and family request for update. Patient in bed, call light within reach." }, { "situation": "", "before": "Incident note: Nobody told me anything about this patient.", "after": "Concern note: Received assignment for patient [ROOM/IDENTIFIER] at [TIME]. Report received from [NAME], RN at [TIME]. Missing [ITEM/INFORMATION] identified at [TIME]. Charge RN [NAME] notified at [TIME]. [ACTION TAKEN]." } ], "words_to_avoid": [ { "wording": "Toxic unit", "why": "It is a conclusion, not a fact.", "instead": "I am resigning effective [DATE]." }, { "wording": "Unsafe", "why": "By itself, it does not show what actually happened.", "instead": "RN assigned [NUMBER] patients from [TIME] to [TIME]; charge RN notified at [TIME] that [SPECIFIC HELP] was needed." }, { "wording": "Nobody cares", "why": "It attacks motives and does not help the next person act.", "instead": "[NAME/TITLE] notified at [TIME]; response was [RESPONSE]." }, { "wording": "Dumped on me", "why": "Loaded wording. It does not describe the handoff.", "instead": "Assignment received at [TIME]; report received from [NAME] at [TIME]." }, { "wording": "Abandoned", "why": "Loaded wording unless your facility has a specific reporting process.", "instead": "No relief RN available as of [TIME]; supervisor [NAME] notified at [TIME]." }, { "wording": "Probably my last day", "why": "Creates scheduling confusion.", "instead": "My last available work shift will be [DATE], [TIME] to [TIME]." }, { "wording": "I refuse", "why": "Sounds personal and combative.", "instead": "I am not available for additional shifts after [DATE]." }, { "wording": "Retaliation", "why": "A serious label without details does not explain the event.", "instead": "Schedule changed from [OLD SHIFT] to [NEW SHIFT] on [DATE]; HR notified at [TIME]." }, { "wording": "Because I am quitting", "why": "Not relevant to patient care.", "instead": "Omit it from the patient chart. Document the patient condition and care provided." } ], "cases": [], "guidance": [ { "says": "Keep the resignation letter short, factual, and respectful. Include the final working day.", "sources": [ { "name": "Nurse.com", "url": "https://www.nurse.com/blog/dos-and-donts-how-to-write-a-nurse-resignation-letter/" }, { "name": "Nursa", "url": "https://nursa.com/blog/quit-a-nursing-job" } ] }, { "says": "Talk to your manager when you can, then send written notice so there is a record.", "sources": [ { "name": "Nursing CE Central", "url": "https://nursingcecentral.com/quitting-nursing-how-to-navigate-a-resignation-conversation/" }, { "name": "Nursa", "url": "https://nursa.com/blog/quit-a-nursing-job" } ] }, { "says": "After you give notice, patient-care documentation does not change. Stick to objective facts: what you observed, what the patient did, what care you provided, and who you notified.", "sources": [ { "name": "CareRev", "url": "https://www.carerev.com/blog/end-of-shift-nursing-note-example-how-to-document-effectively" }, { "name": "Credenza", "url": "https://credenzahealth.com/career-advice/documentation-for-nurses-best-practices" } ] }, { "says": "Use times and concrete details. Skip vague notes.", "sources": [ { "name": "CareRev", "url": "https://www.carerev.com/blog/end-of-shift-nursing-note-example-how-to-document-effectively" }, { "name": "Nursing On Point", "url": "https://nursingonpoint.com/clinical-resources/documentation-laws-regulations/nursing-documentation/" } ] }, { "says": "Make handoff usable for the next nurse: current condition, main risks, changes, and pending follow-up.", "sources": [ { "name": "Patient Talker", "url": "https://www.patienttalker.com/blog/nursing-documentation-sample" }, { "name": "NotuDocs", "url": "https://notudocs.com/en/blog/guides/how-to-document-nursing-assessments-and-shift-handoff-reports" } ] } ], "ready_to_copy": "[NAME], I want to tell you directly that I am resigning from my position as [TITLE] on [UNIT]. My last available work shift will be [DATE], [TIME] to [TIME]. I will send this in writing to you and HR today. I appreciate the opportunity to work here. I will work my assigned shifts and complete handoff responsibilities through that date unless the schedule is changed.", "samples_are_written": true }, { "slug": "job-hunting", "title": "Job Hunting While You Still Work There", "search_title": "Job hunting as a nurse: non-competes, references and what you can take with you", "question": "You are looking for something else. What can you take with you, and what is already signed?", "asked_as": "nurse non compete looking for new job while employed what can I take", "cluster": "shift", "url": "https://shiftiswild.com/notes/job-hunting/", "markdown_url": "https://shiftiswild.com/notes/job-hunting.md", "summary": "You can job hunt while you’re still on the clock somewhere else. That part is allowed. The part that gets messy is mixing your career file with the chart, the EHR, patient info, or anything you already agreed not to take outside work.", "key_points": [ "Keep your own career documents: resume, license verification, certifications, CE records, immunization records, fit-test records, pay/tax records, and personal copies of signed employment documents from HR or the employee portal.", "Do not take patient information, report sheets, patient lists, EHR screenshots, photos, assignment sheets, internal protocols, passwords, badge access, or staff/patient contact lists from work systems.", "Ask for the documents you actually signed: offer letter, employment agreement, confidentiality/HIPAA acknowledgments, non-compete or non-solicit language, repayment agreements, arbitration agreements, outside-employment policy, agency/travel contract limits, and handbook acknowledgments.", "Build interview answers from what you did and what you know how to do. Not from patient identifiers or copied records.", "If a signed agreement matters, read the actual copy and get state-specific help. Do not trust unit gossip about what is or is not enforceable." ], "one_thing": "Take your own career paperwork. Not the facility’s patients, records, systems, or secrets.", "what_goes_wrong": "The usual mistake is treating the workplace like your portfolio folder.\n\nYou start applying somewhere else and want proof that you know your stuff. So you email yourself a report sheet. Save an EHR screenshot. Keep an assignment sheet. Copy a rare case so you can talk about it in an interview. Download policies and skills checklists to your personal drive.\n\nThe reason may be normal: resume update, proof of skills, interview prep. The problem is not intent. It is what you carried out with you.\n\nThose items may have PHI, internal facility information, coworker contact information, or documents covered by policies you already signed.\n\nThe other problem is assuming you remember what you signed. Most of us signed a stack during onboarding: confidentiality forms, HIPAA acknowledgments, outside-employment rules, repayment language for bonuses or tuition, non-solicit language, agency conversion limits, handbook acknowledgments. Before you apply to a competitor, pick up a side gig, or ask a coworker to be a reference, get the paperwork.\n\nThe actual paperwork.", "rewrites": [ { "situation": "", "before": "You want a resume example from a memorable patient", "after": "Room 418, [PATIENT NAME], MRN [MRN], septic shock case from [DATE]. Used Levophed, central line, rapid response, ICU transfer. Good interview example." }, { "situation": "", "before": "You want to show charting skill to a new employer", "after": "Saved screenshots of my EHR note and MAR to show documentation style." }, { "situation": "", "before": "You need procedure or skills examples", "after": "Kept list of patient initials, dates, diagnoses, and procedures so I can prove skills." }, { "situation": "", "before": "You are leaving early or transferring care because of an interview or appointment", "after": "Leaving for interview. Patient is fine. Sam has them." }, { "situation": "", "before": "You want a reference from a provider or charge nurse", "after": "Dr. [NAME] can talk about the patient in 6B and how I handled that code." }, { "situation": "", "before": "You want proof of hours, shifts, or overtime", "after": "Kept assignment sheets and staffing sheets from the unit." }, { "situation": "", "before": "You are checking what you signed", "after": "Downloaded all onboarding files, policy manuals, and unit education folders to my personal Dropbox." } ], "words_to_avoid": [ { "wording": "For my records", "why": "Too vague; can sound like you copied chart or facility material for personal use.", "instead": "Personal employment documents only; no patient information retained." }, { "wording": "De-identified patient list", "why": "Patient lists can still identify people when dates, unit, diagnosis, or rare events are included.", "instead": "Aggregate skills summary with no patient details." }, { "wording": "Screenshot", "why": "Often means an image from the EHR, schedule, chat, MAR, policy site, or internal system.", "instead": "Self-created fictional sample or personal document from HR portal." }, { "wording": "Everyone does it", "why": "Not a fact that helps you later.", "instead": "Followed facility policy; no copy retained." }, { "wording": "Blacklisted", "why": "Speculative and emotional.", "instead": "HR stated [ELIGIBLE/NOT ELIGIBLE] for rehire on [DATE], if confirmed." }, { "wording": "Non-compete is invalid", "why": "Legal conclusion you may not know.", "instead": "Signed agreement located; reviewing obligations before applying." }, { "wording": "They said I could", "why": "Too loose. No person, role, time, or instruction.", "instead": "[NAME], [ROLE], instructed [ACTION] on [DATE] at [TIME]." }, { "wording": "I only used initials", "why": "Initials plus date, unit, diagnosis, or event can still point to a person.", "instead": "No patient identifiers or case details retained." } ], "cases": [], "guidance": [ { "says": "Keep your documentation factual, current, and tied to assessment, care given, notifications, and patient response.", "sources": [ { "name": "NursingCenter", "url": "https://www.nursingcenter.com/journalarticle?Article_ID=517833&Journal_ID=54016&Issue_ID=517824" }, { "name": "PMC", "url": "https://pmc.ncbi.nlm.nih.gov/articles/PMC9183775/" } ] }, { "says": "Treat scratch notes, report sheets, and screenshots with patient information as protected material. Keep them secure and follow facility policy.", "sources": [ { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" }, { "name": "CareerStaff", "url": "https://www.careerstaff.com/clinician-life-blog/nursing/charting-in-nursing-dos-and-donts/" } ] }, { "says": "Make entries and signatures traceable: date, time, signature or credentials, and a clear note on what the signature confirms when needed.", "sources": [ { "name": "SimpleNursing", "url": "https://simplenursing.com/nursing-notes/" }, { "name": "Medscape", "url": "https://www.medscape.com/viewarticle/824924" } ] } ], "ready_to_copy": "[DATE] [TIME]\n\nPersonal career file reviewed for job search.\n\nRetained only the following personal employment documents: [RESUME], [NURSING LICENSE VERIFICATION], [CERTIFICATIONS], [CE RECORDS], [IMMUNIZATION RECORDS], [FIT-TEST RECORDS], [PAY/TAX RECORDS], and [SIGNED EMPLOYMENT DOCUMENTS OBTAINED FROM HR/EMPLOYEE PORTAL].\n\nNo patient records, report sheets, assignment sheets, patient lists, EHR screenshots, photos, room numbers, MRNs, dates of service, internal protocols, staff contact lists, passwords, or facility system files retained.", "samples_are_written": true } ] }