On the stand

What a lawyer asks about your chart

A note written at 0300 gets read two years later by somebody whose job is to find the gap. Each phrase below comes with the questions lawyers have actually asked about it, a real case, what to write instead, and what to do if it is already in your chart.

New phrases are added every week. Latest: .

Exhibit 1 after a fallPatient fell.Did you see it? If nobody saw it, “fell” describes something you did not witness. The note has to show what you saw, what you were told, and who saw what.3 readings with sources · Court of Claims of Ohio, 2020 Exhibit 2 after a fallNo injury noted.What did you check? It is a conclusion. It does not show the assessment behind it, and a fracture or a bleed may not show in the first minutes.3 readings with sources · Court of Appeals of Mississippi, 2012 Exhibit 3 a refusalPatient refused.Refused what? It hides which care you offered, the patient's reason, what you explained, and who you told.4 readings with sources · Appellate Division, Second Department (New York), 2024 Exhibit 4 a refusalNoncompliant.With what? It labels the patient without naming the care offered, the decision, or the reason behind it.4 readings with sources · Ohio Court of Appeals, First District, 2024 Exhibit 5 any shiftMD aware.Aware of what, and since when? It does not say who you reached, what you told them, or what they said back.2 readings with sources · Supreme Court of Nevada, 2010 Exhibit 6 after careTolerated well.Tolerated what? How well? It does not say what you assessed. With findings around it, the same words can hold up.3 readings with sources · Court of Appeal of Louisiana, Fourth Circuit, 2004 Exhibit 7 on roundsPt resting comfortably. Call light within reach.The call system logs every call by itself, to the second. A stock rounding line written at a time you were not in the room is the one record in the file that can be shown wrong.3 readings with sources · U.S. District Court, District of South Dakota, 2014 Exhibit 8 end of a noteWill continue to monitor.Monitor what, and how often? It promises a check without naming it. If no timed entry follows, the chart shows you planned to look and nothing shows that you did.4 readings with sources · Superior Court of New Jersey, Appellate Division, 2026 Exhibit 9 a quick lookNo distress noted.Noted how? It records what you concluded, not what you saw: breathing, color, what the patient said. It also says nothing about whether the care that was due got done.4 readings with sources · Supreme Court of Alabama, 2003 Exhibit 10 a teaching notePatient educated, verbalizes understanding.Educated on what, and what did the patient say back? The phrase records that you taught. It does not show what you covered or what the patient could explain or do. Years later, when nobody remembers the patient, it is all the chart has.4 readings with sources · Appellate Division, First Department (New York), 2022 Exhibit 11 a checkbox in the assessmentWNL.Within normal limits of what, and when did you look? WNL says a finding matched your unit's definition. It does not show the value, what changed, or what is normal for this patient.2 readings with sources · U.S. Court of Appeals for the First Circuit, 1994 Exhibit 12 a high fall risk patientFall precautions in place.Which precautions, and when did you check them? A fall policy is a list: bed low, rails, call light, alarm, room near the station. The label says the list was done without showing which items were on when the patient got up.4 readings with sources · Supreme Court of Mississippi, 2018

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Not legal advice. Your facility policy, your state and your own attorney are what bind you. Every question and every quote here links to where it was published; read the source, not us. Written by a med-surg RN, ten years, day shift. Why there is no name on it.