shift is wild

What you chart every shift

Lines, drains and tubes: what to chart every shift

Why 'lines WNL' tells nobody anything, and what to write for every IV, drain and tube so the chart shows you actually looked

8 min read built on 6 full opinions updated 2026-09-24

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

Maya reacting to this topic

Every shift you check the IVs, central lines, Foley, drains, feeding tubes and trach. The chart has to show three things for each one: you checked it, what you found, and what you did. lines WNL shows none of that. Later, nobody can tell whether you actually looked at the IV site or just clicked through the screen.

The short version

  • Chart each device on its own line or LDA row. Type, location, size, insertion date if you know it. Then what you saw. All lines intact doesn't say which lines.
  • Chart what you saw, not a verdict. The site, the dressing and its date, whether it flushes, what's infusing and at what rate. For drains and tubes, add the amount and what the drainage looks like.
  • Output is a number plus a time window. 220 mL serosanguineous over 12 hr. Not draining well.
  • When something changes, chart what you did. Tube came out, bled, looked wrong? Chart who you told, when, and what they said. If the call isn't charted, the record says it never happened.
  • Don't rewrite the shift. Your start-of-shift note says the dressing is dry, and later you find blood: chart the time you found it. Leave the earlier entry alone.

What goes wrong

Most often, you chart a conclusion instead of the findings behind it. IV patent, site WNL, Foley draining well, JP intact. At 0800 they feel complete. They're only your judgment, and they give the reader nothing to compare against.

That matters because these devices change by the hour. A hematoma grows. A drain goes from serous to bright red. A feeding tube slides out 4 cm. The next nurse, the physician, anyone reading the record later can only see the change if there's a baseline with real details in it. WNL at 0800 and a large hematoma at 1400 tell you nothing about when it started. Now compare an 0800 note that reads R IJ CVC dressing dated 6/10, dry, no swelling at site, neck soft. The change is obvious. So is the fact that you looked.

The second mistake: you chart the finding and skip the follow-up. You did the right thing at the bedside. You replaced the tube, called the physician, put on a pressure dressing. Then you charted only what you found. In the record, whatever you didn't write down didn't happen.

It is not hypothetical

Brenner v. Universal Health Services of Rancho Springs, Inc., California Court of Appeal, 2017. Opinion A patient got a central line in his right internal jugular. The nursing notes right after the procedure recorded the site: "There was a dressing over the site of the central line insertion. No bleeding was indicated from the dressing." His wife described blood on the bedding and early swelling at the neck. Next morning a nurse noticed a lump, checked the insertion site, charted a hematoma and paged the physician. The appeals court upheld summary judgment for the hospital and the physician. The family remembered it differently. The nurses' version stood on those specific site-check entries.

Reginald Lewis v. Cornerstone Hospital of Bossier City, LLC, Louisiana Court of Appeal, 2019. Opinion Trach and PEG. According to the opinion, he pulled out his trach at least three times, and the nurses put it back without notifying the physician. One day the nurses charted dark output in his genitourinary bag, "but did not chart that they notified the doctor of this, either." He pulled out his PEG at 3 a.m. The physician got the call at 8 a.m. The plaintiff's nursing expert went after, among other things, the failure to notify and to document. The jury found no breach of the standard of care, and the appeals court affirmed. Still, much of the trial turned on what the chart did and didn't say about each tube and each call.

Blackshear v. Golden Age Nursing Center, LLC, Louisiana Court of Appeal, 2015. Opinion A physician case, but it's about tubes, so it's about you too. An ER physician replaced a dislodged PEG and said he confirmed placement by auscultation and aspiration, "neither of which was documented in the medical records." The jury found he breached the standard of care but that the breach didn't cause the harm. The appeals court affirmed. You verified placement? Chart how.

Della Sumrall v. Singing River Health System, Court of Appeals of Mississippi, 2015. Opinion Central line removal with the patient sitting in a chair. The patient's position came from the nursing notes and the rapid response entry: "Patient sitting up in chair unresponsive to verbal command." The appeals court reversed the judgment for the hospital and sent the case back to the trial court. When you pull a line, chart the patient's position and your technique. CVC removed isn't enough.

What to write instead

How it often gets charted How to chart it instead
IV patent, site WNLL forearm 20g PIV, inserted 6/12. Site without redness, swelling or tenderness. Dressing dated 6/12, dry and occlusive. Flushes without resistance, blood return present. NS infusing at 75 mL/hr.
Central line intactR IJ triple-lumen CVC. Dressing dated 6/10, dry and occlusive, no drainage. Neck soft, no swelling or bruising at site. All lumens flushed, blood return x3. Distal: norepinephrine per MAR. Medial and proximal: saline-locked.
Foley draining well16 Fr indwelling catheter, placed 6/11. Draining clear yellow urine, 45 mL/hr average over past 4 hr. Tubing without kinks, bag below bladder, securement device on R thigh. Perineal care done.
JP drainingJP #1 R abdomen. Bulb compressed. 40 mL serosanguineous since 0700, emptied at 1500. Site: sutures intact, no redness, small amount of dried drainage on dressing.
Chest tube OKL chest tube to -20 cm H2O suction. No air leak in water seal chamber. Tidaling with respirations. 60 mL serous output since last check. Dressing dry and occlusive. All connections taped.
PEG tube in place, feeds tolerated wellPEG, 18 cm mark at skin (same as 0800 check). Site without redness or drainage. Flushed 30 mL water without resistance. Feeding running at 50 mL/hr per order. Abdomen soft, no distension, no nausea reported.
Trach replaced0215: found trach decannulated. Replaced with spare 6.0 cuffed trach from bedside. Bilateral breath sounds, SpO2 96% on 28% trach collar. 0220: paged Dr. [NAME], who called back at 0225. Orders: continue to monitor. Mitts applied per order.
Hematoma noted, MD aware0640: firm swelling approx 4 x 3 cm at R IJ CVC site, not present at 0400 check. Dressing with small amount of fresh blood. 0645: paged Dr. [NAME], who returned the call at 0650. Order: chest x-ray, pressure dressing. Pressure dressing applied at 0700.

Look at the right column. Every entry names the device, where it is, what you saw, a number where there is one, and what you did next.

Words that do the damage

Word or phrase Why it hurts Replace with
WNLA conclusion with no findings under it. Nothing to compare the next check against.Say what the site looks like: no redness, swelling, drainage or tenderness.
patent (alone)Doesn't say how you know.flushes without resistance, blood return present
intact (alone)The device? The dressing? The skin?Say which: dressing dry and occlusive, sutures intact.
draining wellNo amount, no description.[mL] [color/type] over [hours]
tolerated wellYour impression, no signs behind it.Abdomen soft, no nausea, residual [mL] if checked per policy
MD awareWho? When? What did they order?[TIME] notified Dr. [NAME] by [page/phone]; orders: [ORDERS]
C/D/I with no dateDoesn't show when the dressing was last changed.dressing dated [DATE], clean, dry, intact
Reassessed, no changes (button)Fine for routine checks. Useless if nothing specific was charted at the start.Chart one full baseline entry per device at the start of the shift, then use the button.

What the guidance says

  • Every shift, check and chart each line, drain and dressing: site condition, whether it flushes or drains, anything that needs follow-up. Chart the IV site again every time you change the tubing or dressing. (CareTeam Solutions, NurseChartingPro)
  • Drains: color, consistency, odor and amount, on whatever schedule your unit protocol sets. Drain output counts toward I&O. (Nursing Skills 2e, WTCS, Nursing CE Central)

Copy this

Start-of-shift LDA note

``` [DATE] [TIME] Lines/drains/tubes assessment.

PIV: [SITE], [GAUGE], inserted [DATE]. Site: [no redness/swelling/tenderness OR describe]. Dressing dated [DATE], [dry/occlusive OR describe]. Flushes [without resistance], blood return [present/absent]. Infusing: [FLUID/MED] at [RATE] mL/hr.

Central line: [TYPE, e.g. R IJ triple-lumen CVC / R arm PICC], inserted [DATE]. Dressing dated [DATE], [condition]. Site: [no swelling, bruising, drainage OR describe]. Lumens: [LUMEN] - [INFUSION or saline-locked]; blood return [x NUMBER]. [PICC only: external length [CM] cm, arm circumference [CM] cm if per policy.]

Urinary catheter: [SIZE] Fr, placed [DATE]. Urine [COLOR/CLARITY], [AMOUNT] mL over [HOURS] hr. Tubing without kinks, bag below bladder, securement in place. Catheter care done at [TIME].

Drain: [TYPE AND NUMBER, e.g. JP #1] at [LOCATION]. [Bulb compressed / suction level]. Output [AMOUNT] mL [DESCRIPTION] since [TIME]. Site: [DESCRIPTION].

Chest tube: [SIDE], to [SUCTION LEVEL / water seal]. Air leak [none/present - describe]. Tidaling [present/absent]. Output [AMOUNT] mL [DESCRIPTION] since [TIME]. Dressing [condition]. Connections secured.

Feeding tube: [TYPE], [CM] cm mark at [nares/skin]. Placement verified by [METHOD PER POLICY]. Site [DESCRIPTION]. Flushed [AMOUNT] mL water, [no resistance]. Feeding: [FORMULA] at [RATE] mL/hr. Abdomen [soft/distended], [nausea/no nausea].

Trach: [SIZE AND TYPE], cuff [inflated/deflated]. Stoma [DESCRIPTION]. Ties secure. Spare trach and obturator at bedside. ```

Device dislodged, bleeding or changed from baseline

``` [DATE] [TIME] Found [DEVICE] [WHAT HAPPENED, e.g. dislodged / pulled out / new swelling at site]. Last checked at [TIME]: [FINDINGS AT LAST CHECK].

Assessment now: [SITE FINDINGS WITH SIZE IN CM, DRAINAGE, BLEEDING]. VS: BP [ ], HR [ ], RR [ ], SpO2 [ ]%. Patient [RESPONSE / REPORTS - PATIENT WORDS WITHOUT QUOTES].

Action taken: [WHAT YOU DID, e.g. pressure applied / site covered / spare trach inserted / feeding held].

[TIME] Notified [NAME, ROLE] by [page/phone/in person]. [TIME] Response received. Orders: [ORDERS OR none]. [TIME] [ORDERS CARRIED OUT, e.g. pressure dressing applied / CXR done].

Reassessed at [TIME]: [FINDINGS]. ```

Handoff line for the next nurse

`` [DATE] [TIME] Handoff to [NAME, RN]. LDAs reviewed together at bedside: [LIST DEVICES]. Changes this shift: [NONE OR DESCRIBE WITH TIMES]. Pending: [e.g. dressing change due [DATE] / CXR result / surgeon to evaluate drain]. Output totals this shift: urine [ ] mL, [DRAIN] [ ] mL, [CHEST TUBE] [ ] mL. ``

If you remember one thing

For every device: which one, what you saw, how much came out, and who you called when something changed.

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.

  • if you’re already charting a physical assessment, why would you intentionally neglect to chart on tubes, drains, wounds, etc? you’re already involved in the process of charting…just expand the GU tab and chart the fucking foley.

    r/nursing on Reddit: The death of documentation reddit

  • I’m not surprised. I just moved to the Ed from a level 1 icu and on the icu there you’d have to sell your first born for a central line. It didn’t matter if their ivs failed every flush and they had to get a new one mid shift every shift. I had a pt septic af circling the drain.

    r/nursing on Reddit: Central lines reddit

  • Every 4 hours or so I am charting that I have assessed their lines and drains. So IVs, arterial lines, chest tubes, etc. Intake and output. I usually keep a paper spreadsheet and record all the numbers when I am in the room hourly, So how much ...

    r/nursing on Reddit: What is charting? reddit

  • I spend like 3 at a minimum. ... Dude, you get roasted in CV if you don’t. Surgeons are psychopaths about UO. The foley isn’t that bad though. It’s documenting vitals every time you titrate a drip.

    r/nursing on Reddit: How much time do you spend on documenting during a shift? 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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