Any note: how it gets read

What the intubated patient told you without words

The dropdown offers denies. The patient nodded once. How to chart a nonverbal answer so it never reads like a quote

7 min read built on 1 full opinion updated 2026-10-13

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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Your patient has a tube in their throat. They nod, squeeze your hand, mouth words or tap letters on a board, and you understand something. The chart has to show what they actually did and what you asked. It also has to show how sure you were. Skip that, and someone reads your interpretation as a sentence the patient said.

Key points

  • Chart the method first: nod, head shake, hand squeeze, mouthing, writing, letter board, eye blink.
  • Chart the exact question you asked. Without the question it answered, a nod means nothing.
  • Chart the agreed signal (say, one squeeze for yes and two for no) and when you set it up.
  • Chart whether you read the message back and whether the patient confirmed it.
  • If you couldn't tell what they meant, write that. Unable to determine is a finding. So is silence. But a silent patient isn't a patient with no complaints.

What to write

How it often gets charted What to write instead
Pt states pain 7/10.Pt intubated, RASS 0. Showed 0-10 pain scale on board; pt pointed to 7 twice when asked to point to pain level. Pointed to abdomen when asked where. CPOT 4.
Pt denies SOB.Asked pt whether breathing feels hard. Agreed signal: thumbs up = yes, thumbs down = no. Pt gave thumbs down x2. RR 18, SpO2 96% on current vent settings, no accessory muscle use.
Pt wants to see wife.Pt mouthed a word several times; RN unable to read it. Pt spelled W-I-F-E on letter board. RN read back: you want your wife here? Pt nodded. Wife called at 1415, en route.
Pt agrees to restraint removal plan.Explained plan to remove soft wrist restraints while RN at bedside. Asked pt to squeeze hand once if he understood. Pt squeezed once. Asked pt to squeeze if he would leave the ETT alone; pt squeezed once. Responses consistent x2. Restraints off at 1030, RN at bedside.
Pt no c/o pain overnight.Pt unable to speak (ETT). CPOT 0 at 0000, 0200, 0400. At 0200 asked pt whether he had pain using hand squeeze (1 = yes, 2 = no): pt squeezed twice. No PRN analgesia given.
Pt communicating needs appropriately.Pt writing short words on whiteboard, legible about half the time. Wrote COLD and BACK. Read back: are you cold, and does your back hurt? Pt nodded to both. Warm blanket given, repositioned to L side.
Pt confused, not making sense.Pt mouthing words rapidly; RN unable to identify any word after 3 attempts. Pt did not follow letter board (pointed randomly, did not respond to read-back). RASS +1, CAM-ICU positive. Will reattempt after sedation vacation; MD aware.

Look at any note on the right. Each one shows the method, the question, the observed response and how certain you were.

Template

Message understood and confirmed

[DATE] [TIME]. Pt intubated, unable to speak. RASS [SCORE], CAM-ICU [POSITIVE/NEGATIVE].
Communication method: [NOD AND HEAD SHAKE / HAND SQUEEZE / MOUTHING / WRITING ON WHITEBOARD / LETTER BOARD / PAIN SCALE BOARD].
Agreed signal established at [TIME]: [SIGNAL] = yes, [SIGNAL] = no.
RN asked: [QUESTION AS ASKED, IN PLAIN WORDS].
Pt response: [EXACTLY WHAT PT DID, E.G. NODDED TWICE / SPELLED P-A-I-N / POINTED TO 6 ON SCALE].
RN read back: [WHAT RN SAID BACK TO PT]. Pt [NODDED / SQUEEZED ONCE / GAVE THUMBS UP] to confirm.
Response consistent on [NUMBER] attempts.
Action: [WHAT WAS DONE]. [NAME, ROLE] notified at [TIME].
Reassessed at [TIME]: [FINDING AND HOW IT WAS OBTAINED].

Message not understood, or not sure

[DATE] [TIME]. Pt intubated, unable to speak. RASS [SCORE], CAM-ICU [POSITIVE/NEGATIVE].
Pt attempted to communicate by [MOUTHING / WRITING / GESTURING / LETTER BOARD].
Observed: [WHAT PT DID, E.G. MOUTHED SAME 2-SYLLABLE WORD REPEATEDLY, POINTED TOWARD ETT, WROTE ILLEGIBLE LETTERS].
RN tried: [LETTER BOARD / WHITEBOARD / YES-NO QUESTIONS ABOUT PAIN, POSITION, FAMILY, SUCTION, BATHROOM].
Result: unable to determine pt's message after [NUMBER] attempts.
RN interpretation, not confirmed by pt: [POSSIBLE MEANING, OR NONE].
Pain assessed by CPOT: [SCORE]. Interventions: [WHAT WAS DONE].
[NAME, ROLE] notified at [TIME]. Plan: reattempt with [METHOD] at [TIME OR AFTER SEDATION VACATION / WHEN FAMILY PRESENT].

Handoff line for the next nurse

Communication: pt uses [METHOD]. Yes = [SIGNAL], no = [SIGNAL]. Works best with [WHAT HELPS, E.G. ONE QUESTION AT A TIME, BOARD HELD AT CHEST LEVEL, GLASSES ON]. Reliable when RASS [RANGE]; not reliable when [CONDITION]. Last confirmed message at [TIME]: [MESSAGE AND HOW CONFIRMED]. Unresolved: [ANYTHING PT TRIED TO SAY THAT NOBODY UNDERSTOOD].

Words to avoid

Word or phrase Why it causes trouble What to write instead
states, said, reportsSounds like the patient spoke a sentencenodded when asked…, spelled on letter board…, wrote on whiteboard…
deniesSounds like the patient came up with a no on their ownshook head when asked whether…, squeezed twice (agreed no) when asked…
verbalized understandingThey couldn't verbalize anythingnodded when asked if understood; demonstrated by…
no c/oTreats silence as an answerunable to voice complaints (ETT); CPOT [score]; asked about pain by [method], response [X]
pt communicated that… with no methodThe reader can't tell how you knewName the method and whether you read it back
pt wants…, pt refuses…Turns your interpretation into factpt spelled…, pt pushed RN's hand away when…, RN interpreted this as…; pt confirmed / not confirmed
appropriate, making senseAn opinion with nothing behind itWhat the patient did, and RASS or CAM-ICU if relevant

A gesture turns into a patient quote

The most common mistake is charting a nonverbal exchange in the words you'd use for a patient who talks: Pt states pain 6/10, Pt denies SOB, Pt verbalized understanding. The template assumes a verbal patient and the dropdown offers denies. One click.

The trouble shows up later. Someone opens the chart a week from now, or two years from now. They see states and denies and picture a conversation. They can't see that it was one nod to a yes/no question you picked. Or that the patient was drifting between RASS -1 and -2. Or that you guessed the third letter on the board. Your best reading of a gesture turns into a patient quote.

The opposite mistake does just as much damage. A patient who can't speak doesn't ask for anything. If the chart says no c/o pain or pt not requesting meds, the reader assumes the patient had a way to ask and chose not to. So write down how you checked: CPOT score, a yes/no question with an agreed signal, a pain scale on the board. Leave that out and silence looks like comfort.

Both mistakes come from the same gap. The note doesn't say how the message got from the patient to you.

Bottom line

Chart what the patient did, the question you asked and whether they confirmed it. Then the note never reads as words they couldn't say.

Official guidance

In court, 2010

What happened in 1 court case

George v. Sonoma County Sheriff's Department: District Court, N.D. California, 2010. This patient wasn't intubated. He was a young man with sickle cell disease and an altered level of consciousness, described as non-verbal and unresponsive to questions. Same mechanics, though. According to the opinion's summary of the record, nursing notes recorded that he was not in pain and was non-verbal. The opinion cites a physician's progress note showing that "Ryan would have to verbalize his need for pain medication before it would be administered." His mother testified she was told he wasn't on pain medication because he hadn't asked for it. The order granted the hospital defendants' motion in part and denied it in part. The text we have stops before it gets to the charting, so this article draws no conclusion about how the court treated these notes. The record itself is enough. He couldn't speak. The chart said not in pain, and his not asking was given as the reason he got no medication. Later all of that was read and argued over in federal court.

Court decisions

Published decisions, linked to CourtListener.

All decisions behind this guide

From nurses online

Quoted as written. Opinion, not a source.

Other guides

Advice, not law.