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Time, and what it proves

Charting on paper when the system goes down

The outage is the easy part. The hard part is the recovery, when hours of paper have to go into the EHR at the right times.

7 min read built on 6 full opinions updated 2026-09-27

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

Maya reacting to this topic

The EHR is down and you're on paper. Paper is the easy part. The hard part starts when the system comes back and all of it has to go into the EHR. Here's the goal: anyone who reads your chart later can tell what you did and when you did it. Nothing should look late, missing or doubled.

The short version

  • During downtime, everything goes on the approved downtime forms. That means assessments, vitals, meds, I&O and calls to a provider. Write each one down when it happens, with the actual clock time. Put patient identifiers on every page.
  • When the system comes back, enter each item at the time the care happened. Don't use the time you're typing. The system will still log when you typed it, and that's expected.
  • Label your entries as downtime documentation, not as a plain late entry, and point to the paper source.
  • Check before you enter anything. Someone may have already put some of it in. It could be a downtime MAR that got scanned, meds charted on a downtime device, or I&O totals from another nurse. If you enter them again, you've made duplicates.
  • Mark the paper as entered and send it where your policy says, usually to scanning. The biggest gap is paper that never makes it into the record.

What goes wrong

The entry timestamp isn't the problem. Every EHR logs it, and the audit trail will always show you charting at 15:40 about care you gave at 09:10. That's normal for downtime, and it doesn't count against you.

What gets you is one of four other things:

  1. The care time stays at the default. You chart a 09:10 dose of metoprolol and don't change the time, so it's recorded at 15:40. Now the MAR shows the dose six hours late. If the next one was due at 21:00, it may look like the patient got two.
  2. Nothing says it's downtime documentation. A batch of entries typed hours later with no explanation looks like backcharting. One line saying where they came from answers the question before anyone asks.
  3. The same care goes in twice. Your unit may have downtime devices or a printed MAR that someone reconciles later. If so, the meds may already be in. You enter them again from your paper sheet, and now the record shows two doses.
  4. The paper never gets entered or scanned. You gave the care and the paper sheet shows it. Then the sheet ends up in a drawer. Anyone who reads the chart later sees only the EHR, and in the EHR that care never happened.

There's a fifth, smaller one: approx times. You were writing times on paper as you went. Use those times, not a best guess made at 15:40.

It is not hypothetical

Paige v. Secretary of Health and Human Services, U.S. Court of Federal Claims (Office of Special Masters), 2021. Link A nurse said she got her flu shot on October 9. The vaccine administration form in her employee file was dated November 11. Her affidavit said the paperwork was completed two days after the shot. The special master went with the paper form: "I find that petitioner more likely than not received her vaccination on November 11, 2015 as reflected in her contemporaneous vaccine administration form." Here's what that means for you. Once the date or time on a record is wrong, it's very hard to fix later, even with your own testimony.

United States v. Lillian Akwuba, U.S. Court of Appeals for the Eleventh Circuit, 2021. Link A nurse practitioner testified that she kept handwritten triage sheets with her visit notes. She said they weren't in the files the government's experts reviewed. Her lawyers said it outright: "part of our defense is that these records we’re relying on are incomplete." She was convicted, and the appeals court affirmed. The case was about a lot more than paperwork. Still, it shows that notes kept only on paper can end up playing no part in how a case gets decided.

Hutchinson v. Verstraeten, Superior Court of Pennsylvania, 2023. Link The patient's side claimed the clinic changed her records after the injury. They pointed to the audit trail and to a handwritten change made on a paper record. The trial court excluded their expert, and the jury found for the defense. The appeals court affirmed. These were allegations, not findings. They still led to years of fighting over the audit trail. The plaintiffs' brief, quoted in the opinion, described it this way: "It should show, among other data points, who accessed the records, where and when the records were accessed, and whether changes were made to the records." Your downtime entries will show up in that same log. If they're clearly labeled, the log has nothing to explain.

What to write instead

How it often gets charted How it should be charted
Metoprolol 25 mg PO given. (entered 15:40, time left at default)Administration time set to 09:10. Comment: Downtime entry transcribed from paper downtime MAR. Given 09:10 by [initials].
Late entry. Pt assessed this AM, WNL.Assessment filed at 08:30, with each system actually documented. Comment: Entered after EHR downtime 07:45–14:20 from paper downtime flowsheet.
See paper chart.Downtime 07:45–14:20. All vitals, I&O and meds from paper downtime forms entered at original times. Paper forms sent for scanning per policy.
Pt c/o pain, MD aware, meds given.10:15 Pt reports pain 7/10 R hip. 10:20 Dr. [NAME] notified by phone, verbal order received for oxycodone 5 mg PO. 10:30 given. 11:30 pain 3/10. (Transcribed from paper downtime note.)
I&O totals typed in again after a coworker already entered themCheck the I&O first. If already entered: I&O for downtime period previously entered by [NAME]; verified against paper, no additional entry.
Vitals q4h stable.Each set of vitals entered at its own time: 08:00, 12:00. Comment: From paper downtime vitals sheet.

Words that do the damage

Word / phrase Why it hurts Use instead
late entry (by itself)Suggests you forgot. A downtime entry is a different thing.downtime entry transcribed from paper [form]
see paperPoints to something the reader may never find.Enter the actual data, then note where the paper went.
approx, around, this AMSwaps the times you actually wrote down for guesses.The clock time from the paper form.
charted retrospectivelyVague, and it sounds defensive.entered after EHR downtime [start]–[end]
WNL, tolerated wellTells the reader nothing specific. It's even worse when you write it from memory hours later.The specific findings on the paper form.

What the guidance says

Your facility's downtime policy overrides all of this. That includes which version counts as the official record, paper or electronic. Read the policy before the next outage, not during it.

Copy this

EHR note for the downtime period

``` Downtime documentation. EHR unavailable [START TIME] to [END TIME] on [DATE]. Care during this period documented on paper downtime forms: [LIST FORMS, e.g. downtime MAR, vitals sheet, I&O sheet, nursing note]. The following entered into EHR at original times of care from the paper forms:

  • Vitals: [TIMES]
  • Medications: [DRUG DOSE ROUTE at TIME, one per line]
  • I&O: [TOTALS and TIME PERIOD]
  • Assessments: [TIMES]
  • Provider notifications: [TIME, NAME, what was reported, orders received]

Checked for entries already made by other staff or downtime devices before entering: [NONE FOUND / list what was already entered and by whom]. Not entered: [ITEM and REASON, or NONE]. Paper forms sent to [DESTINATION] for scanning per policy on [DATE] at [TIME]. [YOUR NAME, CREDENTIALS] ```

Note written on each paper downtime form once it's entered

`` Entered into EHR [DATE] [TIME] by [YOUR NAME, CREDENTIALS]. All entries on this page transcribed at original times. Exceptions: [NONE / ITEM and REASON]. ``

Message to the charge nurse if transcription isn't finished

`` EHR downtime [START TIME] to [END TIME] on [DATE], [UNIT]. Patient [NAME / MRN], room [ROOM]: downtime entry [COMPLETE / INCOMPLETE]. Still to enter: [ITEMS, e.g. 12:00 vitals, 13:00 I&O]. Paper forms are located at [LOCATION]. Possible duplicate: [ITEM, e.g. 09:00 metoprolol appears on downtime device and on paper MAR], needs reconciliation before it is entered. [YOUR NAME, CREDENTIALS], [TIME] ``

If you remember one thing

Enter each item at the time the care actually happened, not the time you're typing. Then label it as downtime documentation.

Read the decisions yourself

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

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

What people say on the floor

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

  • When I assumed the care of my patients from a very new, very educated nurse, I did not realize that she would have no idea how to paper chart. Verbal orders were taken that were not written on an order sheet, just mentioned in the notes and never placed on the MAR.

    r/nursing on Reddit: Unplanned Downtime, or Is Paper Charting the New Cursive? reddit

  • Yikes. Are you on Epic? I don’t know about other EHRs, but for Epic we have dedicated downtime devices that download a patient list and MAR and probably some other stuff I’m forgetting every hour, so in case of a downtime, the most recent backup can be printed for use…

    r/nursing on Reddit: What is "paper charts" reddit

  • Wow that is very good practice! Our nursing school taught us med pass with a paper MAR so that was helpful. I always check my meds anyway before scanning them so the only difference was this time I wrote them down! More replies ... Well for one thing, my paper charts never required downtime.

    r/nursing on Reddit: Paper charting reddit

  • OG nurses: Believe or not, I am starting a new job where they still use paper charting (all the time, not just during downtime). Supposedly, there is Epic access (read only?), but with no usable flow sheets or scannable MAR. There are, however, Pyxis machines on the unit.

    r/nursing on Reddit: Old school paper charting reddit

What everyone else says

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

How would you chart it?

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

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