When something goes wrong with a patient or a med

Charting the patient who is getting closer to violence

Agitated, de-escalated, MD aware: three true words that tell the next reader nothing. What to chart so they can watch it build.

7 min read built on 1 full opinion updated 2026-10-18

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

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A patient is getting louder. Pacing, standing too close, saying things that make the room go quiet. Sooner or later you'll write a note. If it says pt agitated, redirected, nobody reading it later can tell what the patient did, what was said, or who knew. Your note should lay out the escalation step by step, with times, so the next shift and anyone reviewing the chart can watch it build.

Key points

  • Chart what you can see and hear: volume, distance, posture, fists, objects, pacing. Skip labels like aggressive or hostile.
  • Copy the patient's exact words. In the real note they go inside quotation marks. Threats most of all. Don't clean up the language.
  • Chart what you did, in order, with times, and how the patient responded to each step.
  • Chart who you told, when, how (phone, in person, page) and what they said or did.
  • Chart as it happens or right after. A short note at 1410 and another at 1435 show the escalation better than one long note at 1900.

What to write

Below, patient speech is in backticks. In your real note, the patient's exact words go in quotation marks.

How it usually gets charted What works better
Pt agitated.1405 Pt standing at nurses' station, voice raised enough to be heard at end of hall, pacing 3 to 4 steps back and forth, fists clenched. States he has waited 3 hours for pain medication.
Pt verbally aggressive toward staff.1412 Pt pointed at this RN and stated: [EXACT WORDS IN QUOTATION MARKS]. Pt standing approx. 2 feet from RN, leaning forward.
Pt threatening.1420 Pt stated he would [EXACT WORDS OF THREAT, IN QUOTATION MARKS], naming CNA [NAME]. Said while looking at CNA, who was in doorway.
De-escalated pt.1414 RN stepped back to approx. 6 feet, spoke in low voice, offered to call provider about pain plan now. Pt continued to pace, voice remained raised. 1418 Offered to sit in room with door open, pt declined, stated: [EXACT WORDS].
MD aware.1416 Dr. [NAME] paged re: escalating behavior and pain request. 1422 Dr. [NAME] returned call, informed of threat toward CNA at 1420. Orders received: [ORDERS]. Plan: [PLAN].
Security called.1421 Security paged via [ROUTE]. 1426 Officers [NAMES] arrived on unit, stationed outside room. Charge RN [NAME] informed at 1421 in person, reassigned CNA [NAME] away from this patient.
Pt calmer.1440 Pt sitting on bed, voice at conversational volume, hands open, answered questions in full sentences. Took PO medication. No further statements about staff.

Nothing in the left column is false. It just gives the reader nothing to act on.

Template

Progress note (one entry per change; add new times as it goes on)

[DATE] [TIME] Behavior note.
Observed: Pt [LOCATION, e.g. in room / at nurses' station]. [OBSERVABLE BEHAVIOR: volume of voice, pacing, posture, hands, distance from staff, objects handled].
Pt stated: [EXACT WORDS, IN QUOTATION MARKS, NO EDITING].
Directed at: [STAFF NAME/ROLE, OTHER PATIENT, NO ONE IN PARTICULAR].
Possible trigger reported or observed: [e.g. wait for medication, visitor leaving, denied request, NONE IDENTIFIED].
Interventions:
  [TIME] [WHAT WAS DONE, e.g. RN increased distance to approx. 6 ft, lowered voice, offered choice of X or Y]. Pt response: [WHAT PT DID/SAID].
  [TIME] [NEXT INTERVENTION]. Pt response: [WHAT PT DID/SAID].
Notified:
  [TIME] Charge RN [NAME], [IN PERSON / PHONE]. Response: [WHAT THEY DID].
  [TIME] [PROVIDER NAME], [PAGE / PHONE / IN PERSON]. Informed of: [BEHAVIOR AND STATEMENTS]. Orders/plan: [ORDERS OR NONE].
  [TIME] Security [NAMES IF KNOWN], [ROUTE]. Arrived [TIME]. Action: [e.g. standby outside room].
Safety measures in place: [e.g. staff assignment changed, room cleared of [ITEMS], observation level changed to [LEVEL] per [NAME]].
Status at [TIME]: [OBSERVABLE BEHAVIOR NOW]. Pt stated: [EXACT WORDS IF ANY].
[YOUR NAME, CREDENTIALS]

Report to charge nurse or provider (SBAR, by phone or in person)

S: This is [YOUR NAME], RN on [UNIT], calling about [PATIENT NAME], room [ROOM]. Over the last [MINUTES/HOURS] his/her behavior has been escalating, and at [TIME] he/she made a statement about harming [WHO].
B: Admitted [DATE] for [REASON]. [KNOWN HISTORY OF VIOLENCE OR ASSAULT, IF DOCUMENTED, OR: NO KNOWN HISTORY IN CHART]. Current meds relevant to behavior: [MEDS/LAST DOSE].
A: At [TIME] pt [OBSERVABLE BEHAVIOR]. At [TIME] pt said [EXACT WORDS]. I tried [INTERVENTIONS] and pt [RESPONSE]. Right now pt is [CURRENT BEHAVIOR]. I am concerned about the safety of [STAFF/PATIENTS].
R: I am asking for [e.g. bedside evaluation within X minutes / order for X / security standby / change in staff assignment / observation level change]. Can you [SPECIFIC REQUEST]?

After the call, chart the time, the person's name, what you reported and what they decided.

Incident or safety event report (your facility's form; this is the narrative part)

Date/time of event: [DATE] [TIME START] to [TIME END]
Location: [UNIT, ROOM OR AREA]
Persons involved: [PATIENT, STAFF NAMES/ROLES, OTHER PATIENTS, VISITORS]
Witnesses: [NAMES/ROLES]

Sequence of events:
[TIME] [WHAT WAS OBSERVED, OBSERVABLE BEHAVIOR ONLY].
[TIME] Pt stated: [EXACT WORDS].
[TIME] [ACTION TAKEN BY STAFF] by [NAME]. Pt response: [WHAT PT DID/SAID].
[TIME] [CONTINUE IN ORDER].

Physical contact or injury: [NONE / DESCRIBE WHAT CONTACT, WHO, BODY AREA]. Seen by: [NAME, TIME] or [NOT YET SEEN].
Notifications: Charge RN [NAME] at [TIME]; [PROVIDER] at [TIME]; Security at [TIME]; Manager/supervisor [NAME] at [TIME].
Measures in place after event: [e.g. assignment change, security standby, observation level, environmental changes].
Prior behavior this admission known to reporter: [FACTS ONLY, WITH DATES/TIMES IF KNOWN, OR: NONE KNOWN TO REPORTER].
Reported by: [YOUR NAME, CREDENTIALS], [DATE] [TIME]

The incident report and the chart note have to match. Should the chart mention the incident report at all? Your facility's policy decides that, so follow it.

Words to avoid

Word or phrase Why it hurts Write instead
agitatedCovers everything from restless to dangerousPacing, volume, posture, what the hands are doing
aggressive / combativeA conclusion with no behavior behind itThe act: swung arm toward RN, threw cup at wall, pushed tray table
threateningThe reader can't judge how serious it wasThe exact words in quotation marks, who they were aimed at, distance
verbally abusiveHides what was saidThe exact words, how loud, how long (e.g. approx. 2 minutes)
hostile / belligerentSounds like your opinion of the personFacial expression, tone, refusals, specific statements
uncooperative / noncompliantDoesn't say what was refused or whyDeclined vitals at 1405, stated: [WORDS]
rude / inappropriateReads like a personal complaintWhat happened, described plainly
de-escalatedNo record of what you triedEach step, with times and how the patient responded
MD aware / charge awareNo name, no time, no responseWho, when, how you reached them, what they said or ordered
calm now / settledDoesn't say what you based it onWhat you observed that shows the change

The summary label erases the timeline

The most common miss is the summary label. Pt became agitated and verbally aggressive, de-escalated, MD aware. Every word of it feels true. The note is still close to useless.

Think about who reads a chart. The next nurse, the security officer, the provider deciding whether to change the plan, a reviewer two years from now. All they get is the page. Agitated could mean anything from sighing loudly to throwing a chair. Verbally aggressive doesn't tell them whether the patient swore at the TV or said they would hurt someone by name. De-escalated doesn't say what you tried, what worked, or whether anything worked. MD aware doesn't say which MD, when, or what they decided.

The label also erases the timeline. Violence rarely comes out of nowhere. It builds, usually over minutes or hours: refusing, then a raised voice, then pacing, then a threat, then moving toward someone. Chart only the endpoint and the record shows a patient who was fine and then suddenly wasn't. The warning signs you saw are gone.

The second miss is not charting who you told. Maybe you told the charge nurse, security and the provider. If the note doesn't say so, the record reads as if nobody outside the room knew.

Bottom line

Write it so someone who wasn't there can see what the patient did, hear what they said, and know who you told and when.

Official guidance

In court, 2015

What happened in 1 court case

Texas San Marcos Treatment Center, L.P. v. Payton: Texas Court of Appeals, 3rd District (Austin), 2015. An aide at an adolescent behavioral health facility sued after a patient assaulted her. She was walking him back alone from an off-unit laundry room. The link goes to the facility's appellate brief. It isn't a ruling. What it does show is what the case was being argued over. The facility's own brief lists the aide's claims, and one of them is that the facility "failed to provide staff with adequate notification of the patient’s assaultive propensity". The facility's brief describes the patient as quiet and cooperative from admission. The aide's brief, filed a few weeks later in the same appeal, says he arrived with a long history of assaultive behavior and that she was never told he could be dangerous. So both sides were fighting over the same questions. What was known about this patient? Where was it written? Did it reach the person on the floor? Your note is supposed to carry exactly that.

Court decisions

Published decisions, linked to CourtListener.

All decisions behind this guide

From nurses online

Quoted as written. Opinion, not a source.

Other guides

Advice, not law.