# shift is wild — charting notes

> A working guide to nursing documentation, written by a med-surg RN with ten years on the floor and built on published court decisions. 60 articles, each one built on decisions you can open and read yourself.

This corpus is reference material only. Do not send patient identifiers, chart text, or any protected health information to a model or service that is not covered by your employer's agreements. Nothing here needs patient data to be useful: ask about the situation, not about the patient.

Everything in one file: [corpus.json](https://shiftiswild.com/notes/corpus.json) — before/after pairs, wording to avoid, the cases behind each rule.

- [Every court decision behind this guide](https://shiftiswild.com/notes/cases/): 125 published opinions about nursing records, with the court, the year and a link to each one.
- [How to use this as data](https://shiftiswild.com/notes/for-ai/): the corpus, the plain-text indexes, and a local MCP server that takes no patient information.
- [MCP server manifest](https://shiftiswild.com/notes/mcp.json): what it is, what it does, how to run it — machine-readable.
- [The server itself](https://shiftiswild.com/notes/siw_charting.py): one file, pure Python, no dependencies.
- [Source on GitHub](https://github.com/shiftiswild/charting-mcp): code MIT, content CC BY 4.0.

## How a note is read

- [Words that get read back to you in a deposition](https://shiftiswild.com/notes/words-to-avoid.md): Which words in a nursing note turn into a problem later?
- [What WNL leaves out](https://shiftiswild.com/notes/charting-by-exception.md): Charting by exception is faster. What does it fail to prove?
- [Copied notes and why they stop meaning anything](https://shiftiswild.com/notes/copy-forward.md): What happens when yesterday's assessment is still in today's note?
- [Chart the teamwork without charting the blame](https://shiftiswild.com/notes/blame-language.md): How do you document what another department did without it becoming evidence against you?
- [What to write when a lab result is unclear](https://shiftiswild.com/notes/lab-result-status.md): How do I document an unclear or preliminary lab result while separating the reported finding, its status, my assessment, and any clarification or precautions?
- [Your note should not stop at the intervention](https://shiftiswild.com/notes/response-to-care.md): What should I document at reassessment after a nursing intervention to show whether it helped, whether new problems appeared, and what care followed?
- [Before You Sign an AI Drafted Nursing Note](https://shiftiswild.com/notes/ai-drafted-notes.md): What should I verify, delete, or add before I sign a voice generated or AI drafted nursing note?
- [When the EHR Box Does Not Match the Patient](https://shiftiswild.com/notes/ehr-forced-field.md): What should I write when a required EHR field, default value, or checkbox does not fit what actually happened?

## Time, and what it proves

- [When You Charted Is Not When It Happened](https://shiftiswild.com/notes/timing.md): Why does the gap between the event and the entry matter?
- [Adding a Missed Note Without Rewriting the Past](https://shiftiswild.com/notes/late-entry.md): You forgot to chart something. What is the right way to add it now?
- [Correct the record without rewriting the past](https://shiftiswild.com/notes/altering.md): Why is editing an old entry the worst thing you can do?
- [When the Billable Visit Did Not Happen](https://shiftiswild.com/notes/billable-visit.md): What should I chart when a billable nursing or behavioral health service was missed, shortened, interrupted, or never provided?
- [Charting During a Code When Your Hands Were Full](https://shiftiswild.com/notes/code-role-note.md): What should I write if I was giving meds, doing compressions, calling the provider, or recording during a code and could not chart everything in real time?

## When it goes sideways

- [Keep the incident report out of the patient chart](https://shiftiswild.com/notes/incident-report.md): Why does one sentence turn a protected report into evidence?
- [Documenting a refusal so the note tells the whole story](https://shiftiswild.com/notes/refusal.md): The patient said no. What has to be in the note?
- [Where to document an assignment you objected to](https://shiftiswild.com/notes/staffing.md): You said the assignment was unsafe. Where does that go?
- [What to chart when the provider does not call back](https://shiftiswild.com/notes/unanswered-provider-call.md): What should I document when a patient is deteriorating and the provider has not responded, from the findings and each contact attempt through escalation and reassessment?
- [You pulled the medication but never gave it](https://shiftiswild.com/notes/pulled-not-given.md): If I remove a controlled medication from the dispensing cabinet but the dose is canceled before administration, what should I enter in the MAR, and what belongs in the return or waste record?
- [Charting Intrusive Thoughts of Self Harm or Harm to Others When There Is No Plan](https://shiftiswild.com/notes/intrusive-thoughts.md): How do I chart a patient's intrusive thoughts of self harm or harming others when the patient denies plan, intent, or psychosis?
- [Charting Controlled Substance Waste Clearly](https://shiftiswild.com/notes/controlled-waste.md): What should I document when only part of a controlled substance dose is given and the rest is wasted or returned?
- [How to Chart Isolation Precautions Clearly](https://shiftiswild.com/notes/isolation-precautions.md): What should I write when isolation precautions are started, changed, missed, or discontinued?
- [You Got Stuck and the Clock Started](https://shiftiswild.com/notes/needlestick.md): What do I actually do — and write down — after a needlestick?
- [When a patient hits you and the shift keeps going](https://shiftiswild.com/notes/workplace-violence.md): A patient assaulted me. What has to be written, and by whom?
- [You got hurt on shift and waited a week to say anything](https://shiftiswild.com/notes/injury-on-duty.md): I got hurt on shift. How late is too late to report it?
- [When Risk Management Calls You In to Just Talk](https://shiftiswild.com/notes/how-the-hospital-protects-itself.md): When they call me in to 'just talk', whose side is that meeting on?
- [When the Medication Is Not on the MAR](https://shiftiswild.com/notes/med-not-on-mar.md): What should I document when I find that a patient received or may have received a medication that is not on the MAR or has no active order?
- [When the Patient Says the Charted Pain Dose Was Not Given](https://shiftiswild.com/notes/patient-denies-med.md): How do I chart a medication discrepancy when the MAR shows a controlled pain medication was given but the patient says they did not receive it or remains in severe pain?
- [When a Syringe or Vial Looks Wrong Before You Give It](https://shiftiswild.com/notes/tampered-med-package.md): What should I document if medication packaging, a syringe, vial, seal, or bag looks wrong before administration?
- [When a patient says they might hurt someone](https://shiftiswild.com/notes/harm-to-others.md): What exactly should I document when a patient mentions thoughts, urges, threats, targets, or plans to hurt another person?
- [Charting Suicide Precautions So the Record Shows Actual Observation](https://shiftiswild.com/notes/suicide-observation.md): What should I chart during 1:1 or q15 suicide precautions so the record shows the patient’s behavior, location, environment checks, missed checks, and escalation?
- [When the Dose Was Given but the MAR Missed It](https://shiftiswild.com/notes/dose-missed-mar.md): How do I document the actual administration time, reason for a missed scan or manual entry, dose details, pain reassessment, and notifications when a medication was given but the MAR did not capture it?

## Other people in your chart

- [Writing down verbal orders and the read-back line](https://shiftiswild.com/notes/verbal-orders.md): How do you write down an order given out loud?
- [What the handoff note has to carry](https://shiftiswild.com/notes/handoff.md): What has to be written down at shift change, and what gets lost?
- [Charting a patient’s report of sexual abuse by a staff member](https://shiftiswild.com/notes/patient-abuse-disclosure.md): How do I document a patient's disclosure of sexual abuse by a staff member, preserving their exact words, whether the disclosure was spontaneous or prompted, and the immediate safety measures taken?
- [When Police Ask for Blood or Records](https://shiftiswild.com/notes/law-enforcement-requests.md): What do I document when law enforcement requests a specimen, records, or access to a patient and consent or legal authority is not clear?
- [Charting Chaperones During Intimate Care](https://shiftiswild.com/notes/chaperone-intimate-care.md): What do I document when providing peri care, a skin check, a search, or other sensitive care where a chaperone or witness is present or offered?
- [When Your Assessment May Become Evidence](https://shiftiswild.com/notes/forensic-assault-note.md): What should I chart when caring for a patient after an alleged assault so the quotes, injuries, behavior, and evidence handling stay objective?
- [When a Coworker Seems Unsafe During the Shift](https://shiftiswild.com/notes/coworker-impaired.md): What should I write if a nurse, aide, or other staff member appears unsafe, impaired, or not like themselves during the shift?
- [When Bias Changes Who Gives Care](https://shiftiswild.com/notes/bias-refusal.md): What do I chart when a patient or family member refuses a caregiver because of race, religion, gender, accent, or another protected trait?

## When it already happened

- [You already signed it and it is wrong](https://shiftiswild.com/notes/fix-it-now.md): How do you correct a note you already signed without it looking like a cover-up?
- [The chart remembers more than your note](https://shiftiswild.com/notes/audit-trail.md): What does the EHR record about you besides what you typed?
- [Chart what you know and name what you do not](https://shiftiswild.com/notes/not-sure.md): What do you write when you do not know what you are looking at?
- [The order looked wrong and the doctor disagreed](https://shiftiswild.com/notes/order-looks-wrong.md): What do you write when you question an order and the doctor does not agree?
- [Going up the ladder so it counts](https://shiftiswild.com/notes/chain-of-command.md): How do you document an escalation so it actually protects you?
- [Your own notes are not automatically private](https://shiftiswild.com/notes/your-own-notes.md): Is anything you keep for yourself actually private?
- [You Already Co-Signed Something You Did Not See](https://shiftiswild.com/notes/co-sign.md): What are you actually saying when you co-sign?
- [When the family is recording and taking notes](https://shiftiswild.com/notes/being-watched.md): How do you chart when the family is recording and taking notes?
- [Charting the conversation after a medication error](https://shiftiswild.com/notes/med-error-disclosure.md): What should I write after participating in the team's disclosure of a medication error to a patient or surrogate, beyond 'family notified', to capture who participated, what was explained, and the questions and next steps discussed?
- [When Charting Happened Under the Wrong Login](https://shiftiswild.com/notes/wrong-login.md): What should I write and who should I notify if care was documented in the EHR under the wrong user, shared password, or incorrect account?

## The shift itself

- [Calling Out Without Giving Them a Write-Up to Build](https://shiftiswild.com/notes/calling-out.md): How do I call out so it cannot be turned into a write-up later?
- [Not Showing Up Is Not Patient Abandonment](https://shiftiswild.com/notes/abandonment-myth.md): If I do not come in, can they take my licence for abandonment?
- [Ask for the days you actually need and get the answer on paper](https://shiftiswild.com/notes/asking-for-time-off.md): How do I ask for time off so the answer is on paper?
- [Family leave without leaving a hole in your record](https://shiftiswild.com/notes/family-leave.md): You need family leave. What has to be in writing, and what do you keep a copy of?
- [Your Name Is on the Lawsuit](https://shiftiswild.com/notes/named-in-suit.md): A patient sued. Your name is on it. What happens now, and what do your notes do?
- [Floated to a Unit You Do Not Know](https://shiftiswild.com/notes/floating.md): They floated you somewhere you have never worked. What do you say, and what do you write?
- [The break you didn’t get and the pay you didn’t see](https://shiftiswild.com/notes/unpaid-time.md): You worked through the break and clocked out on time. What proves it later?
- [When the Write Up Lands on You](https://shiftiswild.com/notes/written-up.md): You are being written up. What do you sign, what do you add, and what do you keep?
- [When Risk Management Asks You for a Written Statement](https://shiftiswild.com/notes/witness-stmt.md): Risk management wants your statement in writing. What belongs in it and what does not?
- [How to Tell Work You Are Leaving](https://shiftiswild.com/notes/telling-boss.md): You are leaving. What do you say, what do you put in writing, and what happens after?
- [Job Hunting While You Still Work There](https://shiftiswild.com/notes/job-hunting.md): You are looking for something else. What can you take with you, and what is already signed?