Orders, handoffs and other people

When the family tells you what they saw another staff member do

A family member saw something you didn't. How to chart their words, your findings, and nothing that reads like a verdict

8 min read built on 0 cases updated 2026-10-29

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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The patient's daughter stops you in the doorway. She says she saw the night aide yank her mother up in bed. Or she saw a nurse pull fluid out of the IV line with a syringe. Or her dad's wallet was on the table before the tech came in, and now it's gone. You didn't see any of it. You still have to chart something, and whatever you write this hour stays in the record for good.

Key points

  • Check the patient first. Look at whatever the report points to: IV site and pump, skin, pain, sedation level, belongings.
  • Tell your charge nurse or supervisor right away, in person or by phone. Follow your facility's policy for this kind of report.
  • In the chart, write who told you, when, and what they said. Make it theirs, and keep it as close to their exact words as you can.
  • In separate sentences, write what you found yourself, who you notified, and what you did.
  • Leave out your conclusions, any comment about the colleague, and any mention of the incident report.

What to write

What often gets written What works better
RN from prior shift drew meds out of pt's IV line. Possible diversion. Supervisor aware.1415 Pt's son [name] at bedside reports that at approx 1300 he saw a staff member insert a syringe into the IV tubing port and withdraw fluid. Pt resting, arousable to voice, oriented x3. RR 16, SpO2 97% RA. R forearm 20g PIV without redness or swelling, NS infusing at 75 mL/hr per pump. Charge RN [name] notified at 1420.
Pt was handled roughly by night aide per daughter. Bruising to arm.0815 Daughter [name] reports that during the night she saw a staff member pull pt up in bed by both arms and that pt cried out. Pt states L arm hurts, rates 4/10. 3 x 4 cm purple bruise to L upper inner arm, not present on admission skin assessment. Full ROM, no deformity. Dr. [name] and nursing supervisor [name] notified at 0830.
Tech stole pt's wallet.1600 Pt's wife reports pt's brown leather wallet was on bedside table at approx 1400 and is no longer in the room. Room, bedside table, linens and pt's bag checked with wife present, wallet not found. Admission belongings list reviewed, wallet listed. Charge RN and security notified at 1610 per policy.
Family upset, concerns addressed.Daughter states she is worried about the care her mother received overnight. Informed her that nursing supervisor [name] will speak with her today. Supervisor at bedside 0845.
Incident report completed. RN Jones to be investigated.Nursing supervisor [name] notified at 0830 of daughter's report and of skin findings above.

Look at the right column. Every note does the same four things. It names who reported and what they said. It keeps that apart from your own findings. It gives times. It records who you told.

Template

Fill in everything in [BRACKETS]. Delete the lines that don't apply. Where a template asks for [EXACT WORDS], put the family member's own words inside quotation marks in your real note. That's how a reader knows the words are theirs and not yours.

Nursing note (patient chart)

[DATE] [TIME]
[RELATIONSHIP] [NAME], at bedside, reports that at approximately [TIME OF EVENT] [HE/SHE/THEY] saw a staff member [WHAT THEY DESCRIBE SEEING]. [RELATIONSHIP] states: [EXACT WORDS].

Patient assessed at [TIME]. [LEVEL OF CONSCIOUSNESS / ORIENTATION]. BP [ ], HR [ ], RR [ ], SpO2 [ ], Temp [ ]. Pain [ ]/10, [LOCATION].
[FOCUSED FINDINGS: IV SITE, PUMP RATE AND VOLUME INFUSED / SKIN, WITH SIZE, COLOR AND LOCATION OF ANY MARKS / BELONGINGS CHECKED AGAINST ADMISSION INVENTORY].
Patient states: [PATIENT'S OWN ACCOUNT, OR UNABLE TO REPORT, OR DECLINES TO COMMENT].

[CHARGE RN / SUPERVISOR NAME] notified at [TIME].
[PROVIDER NAME] notified at [TIME] of findings above. [NEW ORDERS, IF ANY].
[OTHER NOTIFICATIONS REQUIRED BY POLICY, SUCH AS SECURITY], notified at [TIME].
[ACTIONS TAKEN: IV TUBING CHANGED / SITE RESTARTED / ROOM SEARCHED WITH FAMILY PRESENT / OTHER].
[RELATIONSHIP] informed that [SUPERVISOR NAME OR ROLE] will follow up. [RELATIONSHIP'S RESPONSE].

Message to charge nurse or supervisor (call, page, or secure message)

This is [YOUR NAME], RN, caring for [PATIENT NAME] in room [ROOM NUMBER].
At [TIME], the patient's [RELATIONSHIP], [NAME], reported seeing a staff member [WHAT THEY DESCRIBE SEEING] at approximately [TIME OF EVENT]. [IF THEY IDENTIFIED THE STAFF MEMBER: They identified the staff member as [NAME OR DESCRIPTION, AS THEY GAVE IT].]
I did not witness this.
I assessed the patient at [TIME]: [KEY FINDINGS IN ONE OR TWO LINES].
[PROVIDER NAME] has been / has not yet been notified.
The [RELATIONSHIP] is [STILL AT BEDSIDE / HAS LEFT, PHONE NUMBER ON FILE] and is asking [WHAT THEY ARE ASKING FOR].
Please advise on next steps per policy. I am charting the report and my assessment in the patient's record.

Occurrence / incident report narrative

Date and time of report to me: [DATE] [TIME]
Reported by: [NAME], [RELATIONSHIP TO PATIENT]
Date and approximate time of event as reported: [DATE] [TIME]
Staff member involved, as identified by reporter: [NAME, ROLE, OR DESCRIPTION GIVEN BY REPORTER]

Account as given to me: [RELATIONSHIP] stated that [HE/SHE/THEY] saw [WHAT THEY DESCRIBE SEEING, IN THEIR WORDS AS CLOSELY AS POSSIBLE]. [EXACT WORDS, IF ANY STOOD OUT].
I did not witness the event.

My assessment at [TIME]: [VITAL SIGNS AND FOCUSED FINDINGS].
Patient's own account: [PATIENT STATEMENT, OR UNABLE TO REPORT].

Notifications: [CHARGE RN NAME] at [TIME]; [SUPERVISOR NAME] at [TIME]; [PROVIDER NAME] at [TIME]; [SECURITY OR OTHERS PER POLICY] at [TIME].
Actions taken: [WHAT YOU DID FOR THE PATIENT AND THE SCENE].
Other people present at the time of the report: [NAMES AND ROLES, OR NONE].

Completed by: [YOUR NAME, CREDENTIALS], [DATE] [TIME]

Words to avoid

Word or phrase Why it hurts Use instead
stole, tookNames a crime you didn't seeThe item, where and when it was last seen, and who reported it missing
diverted, diversionThat's the investigation's conclusion to reachWhat the family says they saw: syringe, port, tubing, approximate time
rough, abused (in your own voice)It's a judgment. You didn't find itThe movement as the family described it, plus your own skin and pain findings
allegedly, claimsSounds like you doubt the familyreports, states
hysterical, difficult, upset (about the family)Undercuts the person reporting and says nothing clinicalWhat they said or did: tearful, asked to speak with supervisor
incident report filedDrags the separate report into the clinical recordCharge RN [name] notified at [time]
no harm done, unfounded, misunderstandingYou don't know that yetYour findings, stated plainly
per family on its ownThe reader can't tell who said itName and relationship: Pt's son [name] reports
appears to have beenSpeculationLeave it out. Findings only

Charting the family's story as if you saw it

The most common mistake is charting the family's story as if you'd found it yourself. Like this:

Night shift CNA handled pt roughly, bruising noted to L arm.

The nurse who wrote that saw a bruise. She didn't see anyone handle the patient. But the sentence reads as one fact, and nothing in it tells the reader which half she saw and which half she heard.

Here's why that matters. The people reading the chart later weren't in the room. That's the next shift, the provider, quality reviewers, sometimes someone years from now. They'll read every line as something the author knew. Now say the daughter later tells someone she never used the word rough. Or the bruise turns out to be from a fall two days earlier. Your sentence now reads like your own accusation against a coworker, in the medical record.

The second mistake goes the other way. You write nothing, because it feels like gossip or you don't want to get a coworker in trouble. Then the chart shows a family who raised a safety concern and a nurse who apparently never heard it. If something did happen, people will notice the gap.

The third mistake is charting the investigation:

Incident report filed. Supervisor to speak with RN Jones re: possible diversion.

The patient chart is the clinical record. The occurrence report and the supervisor's follow-up are kept separate on purpose, and most facility policies tell you not to mention the occurrence report in the chart. Check yours.

The fix: two kinds of sentences, kept apart.

  • The report: what the family member said, clearly labeled as theirs.
  • Your assessment: what you saw, measured, did, and who you called.

About names. Facilities differ on whether the accused staff member gets named in the patient chart. The full account, names included, goes to your supervisor and into the occurrence report. If your policy does want an identifier in the chart, write the role, or the name and role. No adjective.

Bottom line

What the family said goes in as their words. What you found goes in as yours. No verdict.

Official guidance

  • Chart soon after you take the report and assess the patient, while times and details are still fresh. (NSO, ANA)
  • When a patient or family raises a concern, it goes in the record, along with what you did about it. (NSO, ANA)
  • Start at the nearest level and go up the chain: charge nurse, supervisor, risk manager. (NSO, ANA Code of Ethics)

What this rests on

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

From nurses online

Quoted as written. Opinion, not a source.

Other guides

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