Fixing a note, and who sees it

When the camera saw it too

The footage and your memory won't agree. Write your note first, never edit it to match, and put anything new in a labeled late entry.

7 min read built on 0 cases updated 2026-11-01

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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A patient falls. A visitor swings at you. A code goes sideways, and you know a hallway camera, a room camera or a virtual sitter caught it. You still have to write your note. Days later you might see the footage, and it might not match what you remember.

Key points

  • Chart what you saw, heard and did yourself, as soon as the patient is safe. Write the note before you watch any footage.
  • Didn't see it happen? Say how you found out (alarm, sitter alert, call light, a colleague) and name that source.
  • The video doesn't replace your note. Lines like see camera footage don't belong in your chart.
  • Ask your manager or security to preserve the footage. Don't record it on your phone, and don't forward it yourself.
  • If the footage later shows something that matters clinically, leave the original note alone. Talk to your manager or risk management. Then add a dated, labeled late entry if your facility wants one.

What to write

How it often gets written How it reads better
Pt fell, see video.0215 Called to rm 412 by virtual sitter alert. Pt found on floor beside bed, lying on R side. Pt states (verbatim): [EXACT WORDS]. Unable to say whether head struck floor. Neuro checks initiated, Dr. [NAME] notified 0220.
Unwitnessed fall, pt climbed over rails. (you didn't see the climbing)Did not witness event. Upon entering room at 0215, bed rails x2 up, pt on floor at foot of bed.
Visitor assaulted RN, captured on hallway camera.1430 Visitor (pt's son, per pt) struck this RN on L forearm with open hand at nurses' station. Security called 1431, arrived 1433. Charge RN [NAME] notified. Pt assessed, VS stable, no distress noted.
Pt was combative per sitter, restrained.0310 Sitter alert received: pt pulling at IV. On arrival 0312, pt pulling at L forearm IV, swinging arms toward this RN. Verbal redirection attempted x2 without effect. [Interventions per order/policy, with times.]
Editing your 0215 note to read 0158 after watching the videoOriginal note stays untouched. If time of fall matters for care, add: Late entry [DATE] [TIME]: Following review of event with [NAME, TITLE], time pt was on floor is reported as approx 0158, earlier than 0215 time pt was found. Dr. [NAME] notified of revised timeline at [TIME].
Incident report filed, video requested.Leave this out of the chart. Footage requests and incident reports go through your facility's reporting process.

Template

Chart note at the time of the event

[DATE] [TIME]
How RN became aware: [VIRTUAL SITTER ALERT / BED ALARM / CALL LIGHT / CALLED BY NAME, TITLE].
RN arrived at bedside [TIME]. Did not witness the event itself.
Found: [PATIENT POSITION AND LOCATION, e.g. on floor beside bed, lying on R side].
Environment: [BED HEIGHT, RAILS, ALARM STATUS, FOOTWEAR, LIGHTING].
Pt states (verbatim): [PATIENT'S EXACT WORDS].
Assessment: [LOC/ORIENTATION], [VS WITH TIME], [INJURIES SEEN, SIZE, LOCATION], [PAIN SCORE AND SITE].
Head strike: [YES / NO / UNKNOWN, AND HOW KNOWN].
Interventions: [WHAT WAS DONE, WITH TIMES].
Notified: Dr. [NAME] at [TIME], orders received: [ORDERS]. Charge RN [NAME] at [TIME]. [FAMILY MEMBER NAME, RELATIONSHIP] at [TIME].
Plan: [NEURO CHECKS FREQUENCY / IMAGING / FALL PRECAUTIONS].
[YOUR NAME, CREDENTIALS]

Late entry after new information (use only if your facility asks for it and the difference affects care)

LATE ENTRY. Written [DATE] [TIME], refers to event of [EVENT DATE] [EVENT TIME].
Original note of [ORIGINAL NOTE DATE AND TIME] is unchanged.
Following review of the event with [NAME, TITLE] on [DATE], the following information was received: [CLINICALLY RELEVANT FACT, e.g. pt on floor from approx 0158, not first found at 0215].
Source of this information: [REVIEW WITH NAME, TITLE / SECURITY RECORD AS REPORTED BY NAME].
Clinical action taken: Dr. [NAME] notified at [TIME] of revised information. Orders: [ORDERS OR NO NEW ORDERS].
[YOUR NAME, CREDENTIALS]

Message to manager or risk management

To: [MANAGER NAME], [RISK MANAGEMENT CONTACT]
Subject: Event [DATE], [UNIT AND ROOM], footage preservation request

On [DATE] at approximately [TIME], [ONE-LINE DESCRIPTION, e.g. pt in room 412 was found on the floor].
I documented the event in the chart at [TIME OF YOUR NOTE].
I believe the event may have been recorded by [CAMERA LOCATION / VIRTUAL SITTER / HALLWAY CAMERA NEAR NAME OF AREA], between approximately [START TIME] and [END TIME].
Please arrange for this footage to be preserved under facility policy.

[ADD ONLY IF APPLICABLE:] After [REVIEWING THE FOOTAGE WITH NAME / BEING TOLD BY NAME], I noted that [SPECIFIC DIFFERENCE, e.g. the time pt reached the floor appears earlier than the time I found pt]. My original note is unchanged. Please let me know whether and where this should be documented.

[YOUR NAME, CREDENTIALS]
[UNIT, SHIFT, PHONE OR EXTENSION]

Words to avoid

Word or phrase Why it hurts Use instead
fell (when you didn't see it)Says you saw something you didn'tfound on floor at [TIME]
witnessedOnly true if you saw it live, with your own eyesobserved by this RN or per sitter alert
see video / per cameraPoints the chart at a record that may not be part of itYour own findings, written in full
apparently / must haveA guess that reads like factWhat you found, plus who told you the rest
video confirmsYou're assessing evidence. That's someone else's jobLeave it out of the chart
combativeA label with no behavior attachedWhat the patient did, with the time
incident report filedThat document lives in a separate process, and policy may keep it out of the chartLeave it out of the chart

Writing your note to fit the camera

The usual mistake is treating the camera as the real record and writing your note to fit it. It happens two ways.

Before you watch. You know there's video, so the note gets thin: Pt found on floor, see security footage. But the chart is the clinical record. The next nurse needs your assessment, your times and your interventions in the note itself. So does the provider ordering a CT, and so does the reviewer two years from now. Video can't show neuro checks. It may never get attached to the chart at all.

After you watch. Your note says the patient was found sitting at 0215. The video shows them on the floor at 0158. You'll be tempted to go back and fix the time so it all lines up. Don't. Quietly edit the original and you've turned two honest records into one that looks altered. The EHR logs every edit with your name and the time, so the change will show. What you remembered and what the video showed later are both real information. Keep them separate and label them.

There's a memory problem too. Watch the footage before you write, and you may start remembering the video instead of the event. Details from the screen slip into your account. You won't notice. So write first and watch later, if you watch at all.

A few related situations:

  • The camera saw the event and you only saw the aftermath. That's normal. Write found on floor. Don't write fell. What the virtual sitter caught belongs to the sitter's record. You didn't observe it.
  • The footage differs on small details. You remember standing on the left, and the video has you on the right. Most of the time that stays out of the chart because it doesn't change care. Tell whoever is reviewing the event and let your facility decide where it gets written down.
  • Whether the chart mentions the camera at all depends on facility policy. Some facilities want the note to say security was called or a sitter alert fired. Others keep anything about footage in the incident report only. Ask your manager or risk management. Don't guess.

Bottom line

Write your own account first and keep it as you wrote it. Anything you learn later goes in a separate entry, dated and labeled.

Official guidance

  • Chart soon after the event, while details are fresh. Don't count on your memory at the end of a long shift. (NSO, A Security Training Academy)
  • Never change the original entry. New or corrected information goes in a separate addendum or late entry with its own date and time. (NSO, Security Force USA)
  • Keep what you saw, heard and did yourself apart from what someone told you or a system showed you. Name the source. (NSO, GCTactical)
  • If an incident report mentions footage, give the camera or location and the time window. Ask for it to be preserved before it's overwritten. And don't claim the video shows more than it does. (GCTactical, Security Force USA)

What this 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.

From nurses online

Quoted as written. Opinion, not a source.

Other guides

Advice, not law.