shift is wild

When it goes sideways

The bruise nobody charted

The family found it first. Here's how to chart it without guessing, blaming anyone or touching the last shift's note.

7 min read built on 0 cases updated 2026-09-25

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

Denise reacting to this topic

A daughter comes in, pulls back her mother's sleeve and shows you a bruise. It isn't in the last skin assessment. Now you chart it: what you see, when you saw it, what the last check recorded and who you told. Don't guess at a cause. Don't blame anyone. Don't touch the earlier entry.

The short version

  • Look before you write. Assess the site yourself: location, size in cm, color, swelling, tenderness and what the patient says about it.
  • Describe the gap with two timestamps. When was the last skin check, and what did it record for that spot? When did this finding come up, and who pointed it out? Write both down. Leave the time between them alone. Don't explain it.
  • Leave the old entry alone. If you're adding something to an earlier assessment, mark it as a late entry with today's date and time.
  • Notify, then chart that you did. Tell the charge nurse, the provider and anyone else your policy names. Write down who, when, and what they said or ordered.
  • File the report through the facility process. File the incident or occurrence report according to policy. The clinical facts go in the chart. The report is a separate document.

What goes wrong

The most common mistake is trying to explain the gap. Probably from the bed rail. Old bruise, likely present on admission. Missed on prior assessment. Each one feels helpful. Each one claims something you didn't see.

Here's why that's a problem:

  • Your guess becomes the official story. Once bed rail is in the chart, the next person reads it as fact. If the cause turns out to be something else, the record contradicts itself.
  • Color doesn't tell you age. Calling a bruise old or new because of how yellow it is sounds clinical. It's still a guess. Write the color you see and stop there.
  • Blame in the chart won't do what you want. Missed on prior assessment is about a colleague, not the patient. Family upset and accusatory is about the family's mood, not the injury. Neither tells the next clinician anything useful.
  • Saying too little is the opposite mistake. Bruise noted to L arm with no size, no time reference and no notification looks like a finding nobody followed up on.

The fix is the same both times. Record the time and what you observed. Nothing else.

It is not hypothetical

No case in our set speaks to this directly.

What to write instead

How it often gets written How it could be written
Bruise found on L arm by daughter. Probably from BP cuff.1540: Patient's daughter pointed out discoloration on L upper arm. On assessment: purple-blue area, 4 cm x 3 cm, lateral L upper arm, 5 cm above elbow. No open skin. Mild tenderness on palpation per patient, 2/10. Last documented skin assessment 0800 today, L upper arm recorded as intact, no discoloration.
Old bruise on R hip, yellowish, prob. present on admit.R lateral hip: yellow-green discoloration, 6 cm x 5 cm, irregular border, no swelling, no open area. Patient states she does not recall how it happened. Admission skin assessment [date] 1900 does not document a finding at this site.
Family very upset, accusing staff. Reassured.Son at bedside asked about swelling to R wrist. Findings reviewed with son. Charge RN J. Park notified at 1615 and came to bedside at 1625.
Swelling R wrist, pt fine, WNL otherwise.R wrist: swelling dorsal aspect, circumference 17 cm (L wrist 15.5 cm). Warm to touch. Radial pulse 2+, cap refill under 3 sec, fingers warm, moves all fingers. Patient reports pain 5/10 with movement.
Missed on prior shift assessment.Last documented skin assessment 0800 [date] by day RN does not include this site. Finding first documented this entry.
No injury earlier, happened sometime this afternoon.Last documented skin assessment 1200. Finding observed 1710.
MD aware.1630: Dr. A. Mendez paged re: R wrist swelling and findings above. Callback 1642. Orders received: R wrist X-ray, ice 20 min q2h, reassess neurovascular status q2h.

Look at what these have in common. The gap is just two times sitting next to each other. You don't write anything to connect them.

Words that do the damage

Word or phrase Why it hurts Use instead
probably, likely, must haveYou're naming a cause you didn't witnessWhat you observed, plus the patient's own account if they give one
old bruise / new bruiseIt guesses age from colorThe color you see: yellow-green, purple-blue
appears to beIt hedges and adds nothingMeasurements and a plain description
missed on prior assessmentIt blames a colleague. It isn't a clinical findingLast documented skin assessment [time]; site not described
no injury present earlierYou're asserting something you didn't check yourselfLast documented skin assessment [time] records [site] as [finding]
occurred between X and YIt implies you know when it happenedTwo separate timestamps: last check, then finding
family upset / hostile / accusatoryIt's about mood, not the patientWho was present, what they asked about, who you notified
WNL, tolerated wellVague shorthandThe specific finding
incident report filedMany facilities don't want this in the chart. Check your policyChart the facts and the notifications. File the report through its own channel

Injury of unknown origin is fine if your facility uses it. It's neutral. It doesn't guess.

What the guidance says

  • For each finding, write down where it is and what it looks like: anatomic location, size, shape, color and anything else that sets it apart. Some skin findings can look like bruising, so be exact. (cod.pressbooks.pub, nursing.com)
  • Ask the patient when they first noticed it and whether it hurts. Write down what they say. (nursing.com, rcemlearning.co.uk)
  • The injury and your follow-up go in the patient's medical record, not only in a separate report. (justanswer.com, advantismed.com)

Copy this

Nursing note in the chart

``` [DATE] [TIME] Skin finding identified by [RELATIONSHIP / VISITOR NAME] at bedside.

Assessment: Location: [SIDE] [BODY AREA], [LANDMARK, e.g. 5 cm above elbow, lateral aspect]. Size: [LENGTH] cm x [WIDTH] cm. Color: [COLOR AS SEEN]. Border: [REGULAR / IRREGULAR]. Skin integrity: [INTACT / OPEN AREA, describe]. Swelling: [NONE / PRESENT, measurement if taken]. Warmth: [YES / NO]. Tenderness: [NONE / PRESENT], pain [SCORE]/10 [AT REST / WITH MOVEMENT]. For extremity: pulse [GRADE], cap refill [SECONDS], sensation [INTACT / ALTERED], movement [DESCRIBE].

Patient account: Patient states [PATIENT'S OWN WORDS, paraphrased or verbatim] / Patient unable to describe onset.

Prior documentation: Last documented skin assessment [DATE] [TIME] by [ROLE]. [SITE] recorded as [WHAT WAS RECORDED / not described].

Notifications: [TIME] Charge RN [NAME] notified. [TIME] [PROVIDER NAME] notified by [PHONE / PAGE / IN PERSON]. Orders received: [ORDERS / none at this time]. [TIME] [FAMILY MEMBER / POA NAME] informed of findings and plan.

Interventions: [ICE / ELEVATION / IMAGING ORDERED / PADDING / OTHER]. Plan: Reassess site [FREQUENCY]. [OTHER FOLLOW-UP PER ORDERS].

[YOUR NAME, CREDENTIALS] ```

Late entry (if you're adding to an earlier assessment)

`` LATE ENTRY for [ORIGINAL DATE] [ORIGINAL TIME], written [TODAY'S DATE] [CURRENT TIME]. Addendum to skin assessment of [ORIGINAL DATE] [ORIGINAL TIME]: [WHAT YOU OBSERVED AT THAT TIME AND DID NOT RECORD]. Reason for late entry: omitted from original documentation. [YOUR NAME, CREDENTIALS] ``

Notification to provider or charge nurse (SBAR)

``` S: This is [YOUR NAME], RN on [UNIT], calling about [PATIENT NAME], room [ROOM NUMBER]. A [SIZE] cm x [SIZE] cm [COLOR] area on [LOCATION] was pointed out by [RELATIONSHIP] at [TIME]. Not described in last documented skin assessment at [TIME].

B: Admitted [DATE] for [DIAGNOSIS]. Relevant: [ANTICOAGULANTS / FALL RISK / MOBILITY STATUS / RECENT PROCEDURES OR DEVICES AT THAT SITE].

A: [SWELLING / TENDERNESS / PAIN SCORE / NEUROVASCULAR STATUS]. Vitals [VITALS]. Patient states [PATIENT ACCOUNT / unable to describe onset].

R: Requesting [EVALUATION / IMAGING / ORDERS]. Family [NAME, RELATIONSHIP] is at bedside and asking for an update. ```

Incident or occurrence report narrative (file per facility policy)

``` On [DATE] at [TIME], [VISITOR NAME, RELATIONSHIP] identified a skin finding on [PATIENT NAME]'s [LOCATION] and reported it to [YOUR NAME, ROLE].

Assessed at [TIME]: [SIZE] cm x [SIZE] cm, [COLOR], [INTACT / OPEN], [SWELLING / TENDERNESS DETAILS].

Last documented skin assessment: [DATE] [TIME]. [SITE] recorded as [WHAT WAS RECORDED / not described].

Patient account: [PATIENT'S STATEMENT / unable to describe onset].

Notified: Charge RN [NAME] at [TIME]; [PROVIDER NAME] at [TIME]; [FAMILY / POA NAME] at [TIME]; [OTHERS REQUIRED BY POLICY] at [TIME].

Actions taken: [INTERVENTIONS, ORDERS, SAFETY MEASURES].

Reported by: [YOUR NAME, CREDENTIALS], [DATE] [TIME]. ```

If you remember one thing

Describe what you see. Put down two timestamps: the last check and this finding. Don't write anything that explains the time in between.

What this one 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.

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.

  • I was a brand new ED nurse and had an infant that had obviously been beaten...a year later I was in court testifying against the mother's boyfriend who was charged with · child abuse...I asked for a copy of the chart before hand from the prosecutor...the only thing I had charted was that the ch

    r/nursing on Reddit: “Document/chart like you’re going to court” reddit

  • Recently at a conference someone presented about how increased RR is often the earliest sign of decompensation and the most frequently missed because we all just look at the patient and say 14 or 16 ... My senior year of nursing school and I took the longest on every assessment, eventually my instru

    r/nursing on Reddit: What is something that isn’t documented well that should be documente reddit

  • I tag off with "nil further concerns voiced by patient (± or family) at time of writing". Always the option to addend notes if they raise further concerns ... Recognize when you’re feeling pissy towards a patient when writing a narrative note. Word choice and syntax can sneak up on you. Be

    r/nursing on Reddit: What are your documentation do’s and dont’s ? reddit

  • ED nurse here - we’re not known for our charting (and I’m a minimalist on top of that), but I’d recommend you start with your unit policies on required documentation. Chances are you’re required to document certain things at certain intervals: assessments, pressure ulcer risk, etc. Aside from the re

    r/nursing on Reddit: Nurses notes documentation advice 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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