shift is wild

Other people in your chart

When your assessment may become evidence

Your note may be boring now and very interesting later. Here’s how to make it survive daylight.

12 min read built on 6 full opinions updated 2026-09-19

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

Denise reacting to this topic

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.

The short version

  • 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.

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.

A better note keeps four things separate:

  1. What the patient said.
  2. What you observed.
  3. What you assessed or treated.
  4. What happened to possible evidence.

That 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.

It is not hypothetical

  • State v. Toomes, Court of Criminal Appeals of Tennessee, 2005. 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.”
  • State v. Robinson, Ohio Court of Appeals, 2012. 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.”
  • Neighbors Rehab. Ctr., LLC v. U.S. Dep't of Health & Human Servs., Court of Appeals for the Seventh Circuit, 2018. 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.”

What to write instead

Instead of this Write this
Patient was raped by boyfriend.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].
Patient hysterical and making accusations.Patient crying, hands trembling, respirations 24/min, speech clear, answered questions in short phrases. Patient stated exact words: [PATIENT EXACT WORDS].
Multiple bruises all over body.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.
No injuries noted.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.
Rape kit done and given to police.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].
Clothes bagged.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].
Patient drunk and unreliable.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.
Visitor threatening and aggressive.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.
Patient uncooperative with exam.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 that do the damage

Some words carry more than your note can prove. Use what you actually have.

Word or phrase Why it causes trouble Use instead
victimIt is a legal or advocacy label, not an assessment finding.patient
perpetratorIt names a legal role you may not be able to determine.person identified by patient as [RELATIONSHIP/NAME]
alleged victimIt can sound like disbelief and adds no clinical detail.patient reports [EVENT]
rapedUse only if recording the patient’s exact word or a documented diagnosis by the appropriate clinician.patient stated exact words: [PATIENT EXACT WORDS]
assaultedSame problem as above unless it is the patient’s word or a report category required by your facility.patient reports being [HIT/GRABBED/TOUCHED/HELD DOWN/etc.]
hystericalIt is judgmental and vague.crying, trembling, pacing, speaking rapidly, unable to sit still
combativeIt does not say what happened.pulled arm away, pushed call bell onto floor, kicked toward staff, declined exam
intoxicatedIt may be a conclusion unless backed by findings or test results.odor of alcohol, slurred speech, unsteady gait, test result [RESULT]
no evidence of assaultThat is too broad and sounds like a legal conclusion.no visible injury noted to [BODY AREAS ASSESSED] at [TIME]
kit doneIt skips who collected it, when, and what happened to it.kit [NUMBER] collected by [NAME/TITLE], sealed at [TIME], transferred to [NAME/TITLE/BADGE] at [TIME]

What the 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. (LibreTexts/20:_Psychosocial_Assessment/20.03:_Abuse_and_Neglect_Assessment), RN.org)
  • Chart what you can observe: appearance, behavior, demeanor, exam findings, statements, and nonverbal behavior. (BUMC, RegisteredNursing.org)
  • 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. (My American Nurse, RN.org)
  • 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. (LibreTexts/20:_Psychosocial_Assessment/20.03:_Abuse_and_Neglect_Assessment), ForensicSpot)

Copy this

Medical record note

```text [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].

Patient stated exact words: [PATIENT EXACT WORDS].

Patient 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].

Observed 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.

Vital signs at [TIME]: BP [BP], HR [HR], RR [RR], SpO2 [SPO2], Temp [TEMP]. Neuro status [FINDINGS IF ASSESSED]. Pain reassessed at [TIME]: [RESULT].

Injury assessment completed with patient permission. Findings:

  1. [BODY LOCATION]: [SIZE], [COLOR], [SHAPE], [TYPE OF INJURY], [TENDERNESS], [DRAINAGE/BLEEDING], [SKIN INTACT/OPEN].
  2. [BODY LOCATION]: [SIZE], [COLOR], [SHAPE], [TYPE OF INJURY], [TENDERNESS], [DRAINAGE/BLEEDING], [SKIN INTACT/OPEN].

No 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].

Potential 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].

Provider [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]. ```

Evidence transfer note

```text [DATE] [TIME] Evidence transfer completed for [ITEM OR KIT NUMBER]. Item collected by [NAME/TITLE] during [EXAM OR CARE ACTIVITY] from [START TIME] to [END TIME]. Item packaged in [CONTAINER TYPE], labeled with [PATIENT IDENTIFIERS], item description, date, time, and collector initials. Seal number [SEAL NUMBER] applied at [TIME]. Seal intact at time of transfer.

Item remained in [SECURE LOCATION] from [TIME] to [TIME]. Item transferred by [NAME/TITLE] to [RECEIVING NAME/TITLE/BADGE/AGENCY] at [TIME]. Patient identifiers and item label verified by [NAMES]. Chain-of-custody form signed by [NAMES]. No other handling of item noted by this writer. ```

Supervisor notification

```text [DATE] [TIME] Notified [SUPERVISOR NAME/TITLE] regarding patient [PATIENT NAME/MRN] after patient-reported assault. Information reported: patient stated exact words [PATIENT EXACT WORDS]; observed findings include [BRIEF OBJECTIVE FINDINGS]; safety concern is [SAFETY CONCERN].

Actions already taken: patient moved to [PRIVATE OR SAFE LOCATION] at [TIME]; provider [NAME] notified at [TIME]; SANE or forensic nurse [NAME] notified at [TIME]; security or other support [NAME] notified at [TIME]; potential evidence items secured per facility policy as [DETAILS].

Direction received from supervisor: [DIRECTION]. Follow-up assigned to [NAME/TITLE]. Patient remains in [LOCATION] with [SAFETY MEASURE]. ```

Internal safety report if required by policy

```text [DATE] [TIME] Internal safety report completed by [NAME/TITLE]. Patient [PATIENT NAME/MRN] reported [BRIEF PATIENT-REPORTED EVENT] occurring at [LOCATION] on [DATE] at approximately [TIME]. Patient exact words recorded in medical record at [TIME]. Objective findings at time of report: [INJURY FINDINGS], [BEHAVIOR OBSERVED], [SAFETY CONCERNS].

Staff notified: [NAMES/TITLES/TIMES]. Immediate actions: [PATIENT MOVED TO PRIVATE AREA], [MEDICAL ASSESSMENT COMPLETED], [EVIDENCE SECURED], [SECURITY NOTIFIED], [SANE OR FORENSIC NURSE NOTIFIED], [OTHER]. Evidence or property handled: [ITEMS], [CONTAINERS], [SEAL NUMBERS], [STORAGE OR TRANSFER DETAILS]. Follow-up requested: [FOLLOW-UP]. Report submitted to [NAME/TITLE/DEPARTMENT] at [TIME]. ```

If you remember one thing

Chart the patient’s exact words. Chart what you saw. Chart the exact path of any evidence.

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.

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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