shift is wild

When it goes sideways

The doses are charted but the pain Isn't moving

Doses given, pain not moving. How to chart the pattern, call the prescriber and keep a colleague's name out of a legal document.

7 min read built on 3 full opinions updated 2026-09-28

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

Maya reacting to this topic

Your patient has had an opioid every few hours. Some of those doses you charted, some were charted by other nurses, and the pain score hasn't moved. The dose could be too low, the plan could be wrong, or it could be something else. You don't have to figure out which. You have to get the pattern into the chart as plain facts and send it up the chain. Nobody gets accused.

The short version

  • Reassess after every opioid dose and write down the number, what you saw and the time. A dose with nothing after it tells the next reader nothing.
  • Chart three things side by side: the MAR, the patient's report, your own observations. The timestamps will show the pattern. You don't have to explain it.
  • If the plan isn't controlling the pain, say so in your assessment and call the prescriber. Then chart who you told, when, and what they said.
  • Your theories about a colleague don't go in the chart. Ever. If the count, the waste or the timing doesn't add up, report it through the incident or pharmacy process, and keep the tone just as flat.
  • Chart only what you saw, measured or were told. No guesses, no labels, no feelings.

What goes wrong

The entry you'll see most often is a dose with nothing after it. Medicated per order, tolerated well, then two hours of silence, then the next dose. By the end of the shift the MAR looks full, and there's still no data on whether any of it worked.

That leaves you with three problems:

  1. **No one can tell didn't work from wasn't received.** Say there's no pain score 30–60 minutes after the dose. A reviewer can't tell whether the drug failed, the dose was too small or the patient never actually got it. Without reassessments, all three look the same on paper.
  2. The next nurse has no baseline. The day nurse charted resting comfortably and you walk in to a 9/10. Did something change, or was the pain never under control? You can't tell.
  3. The prescriber never sees a pattern. One high score looks like a bad moment. Six high scores after six doses mean the plan isn't working. The prescriber only finds out if someone writes it down and picks up the phone.

Nurses also make the opposite mistake. Someone notices something is off and charts a theory: pt states previous nurse didn't give med, ?diversion, questionable administration. That's an accusation, built on an inference, sitting in a permanent legal document. The chart holds facts. The concern goes somewhere else (see Copy this below).

It is not hypothetical

Christus Health Gulf Coast d/b/a Christus St. John Hospital v. Jay Houston, Texas Court of Appeals, 1st District (Houston), 2015. https://www.courtlistener.com/opinion/4273885/christus-health-gulf-coast-dba-christus-st-john-hospital-v-jay-houston/

A caveat first. This is the patient's appellate brief, not the court's opinion, so you're getting one side's account. According to the brief, after a shoulder surgery "Jurors found Christus nurses negligent for failing to alert Dr. Holt to symptoms of ischemia". The brief says the problem went on for days before anyone corrected it. The patient's hand was left permanently disabled.

The case is about ischemia, not pain medication. The mechanism is the same, though. A finding kept showing up, and according to the brief, nobody told the physician. Pain that stays high dose after dose is a persistent finding too. You escalate it, and the escalation goes in the chart.

What to write instead

How it usually gets charted What works better
Medicated per order, tolerated well.1410 hydromorphone 1 mg IV given per MAR. 1440 reassess: pain 8/10 abd, unchanged from 1400. Guarding, HR 108, unable to reposition without assist.
Pt c/o pain again, med given.1830 pt reports pain 9/10 incision, sharp, constant. Per MAR, oxycodone 10 mg PO last documented 1630. Pt states pain has not dropped below 8 since this morning. VS: HR 112, BP 158/92, RR 20.
Pain uncontrolled, will continue to monitor.Pain scores after last 4 doses per MAR (0600, 1000, 1400, 1800): 8, 9, 8, 9. Current PRN regimen not controlling pain. Dr. [NAME] paged 1845.
Notified MD.1850 spoke with Dr. [NAME] by phone. Reported pain 8–9/10 after each dose since 0600, VS as above. New order received: [ORDER]. Read back and confirmed.
Pt drug-seeking, requesting meds early.2100 pt requesting pain med. Next PRN dose available 2230 per order. Pt reports pain 9/10, rocking in bed, diaphoretic. Charge RN [NAME] and Dr. [NAME] notified 2105.
Previous shift may not have given med, pt says no relief.Pt states last dose she recalls receiving was approx 1300. MAR shows doses documented 1300 and 1600. Pain 9/10 on assessment 1700. (Anything beyond this goes in the incident report, not the chart.)

Look at the last row. It has what the patient said, what the MAR says and what you found. You don't reconcile them, and you don't guess why they differ. Putting the facts next to each other does the job.

Words that do the damage

Word or phrase Why it hurts Use instead
tolerated wellSays nothing about pain reliefPain score + time + what you observed
resting comfortablyA conclusion, not an observation, and it may be wrongeyes closed, RR 16, no grimace when repositioned at [TIME]
drug-seekingA label that can follow the patient and color everyone's careDescribe the request, the timing and your assessment
?diversion, suspect, questionableAn accusation with no facts behind it, in a permanent recordNothing in the chart. Use the incident or pharmacy report.
not sure it was givenSpeculation about a colleagueMAR shows [DOSE] at [TIME]. Pt reports [WHAT PT SAID].
will continue to monitorSuggests the pattern was noticed but nobody actedWho you notified, when, and the response
notified MDNo name, no time, no contentDr. [NAME] paged [TIME], reported [FINDINGS], response: [RESPONSE]

What the guidance says

  • Charting that the dose was given isn't enough. Opioids need ongoing, documented reassessment of how the patient is doing, especially early in therapy and when doses are scheduled. (NCBI Bookshelf, NC Board of Nursing)
  • If the current plan isn't controlling the pain, you say so in your nursing assessment and report it to the prescriber. (Michigan LARA, NurseBrain)

Copy this

Chart note (nursing progress note)

`` [DATE] [TIME] Pain reassessment. Pt reports pain [SCORE]/10, [LOCATION], [QUALITY: sharp/dull/burning/etc.]. Per MAR, analgesic doses documented this [SHIFT/24H]: [TIME] [DRUG] [DOSE] [ROUTE] - reassessed [TIME], pain [SCORE]/10 [TIME] [DRUG] [DOSE] [ROUTE] - reassessed [TIME], pain [SCORE]/10 [TIME] [DRUG] [DOSE] [ROUTE] - reassessed [TIME], pain [SCORE]/10 Observed: [HR], [BP], [RR], [SpO2], sedation level [SCALE/SCORE]. [GUARDING / GRIMACING / UNABLE TO AMBULATE / UNABLE TO SLEEP - what you actually saw]. Pt states [WHAT PT SAID ABOUT RELIEF, IN PT'S WORDS, NO QUOTATION MARKS]. Nursing assessment: pain not controlled with current regimen. [TIME] [PRESCRIBER NAME AND ROLE] notified by [PAGE/PHONE/IN PERSON]. Reported the above. Response: [NEW ORDER / NO NEW ORDERS / WILL EVALUATE AT BEDSIDE]. [IF NEW ORDER: order read back and confirmed. Next reassessment planned at TIME.] [YOUR NAME, CREDENTIALS] ``

Call to the prescriber (SBAR, say it and then chart it)

`` S: This is [YOUR NAME], RN on [UNIT], calling about [PT NAME], room [ROOM]. Pain is not controlled on the current orders. B: [DIAGNOSIS / PROCEDURE, POST-OP DAY]. Current analgesic orders: [LIST]. Per MAR, doses documented at [TIMES]. A: Pain scores after those doses: [SCORES WITH TIMES]. Current VS [VALUES], sedation [SCORE]. I am seeing [OBSERVED BEHAVIOR / FUNCTION]. R: I am asking you to [EVALUATE AT BEDSIDE / REVIEW THE REGIMEN / CONSIDER ALTERNATIVE]. Can you give me orders or tell me when you will see the patient? ``

Report to charge nurse, manager or pharmacy (only if the records don't reconcile)

``` To: [MANAGER / PHARMACY / INCIDENT REPORTING SYSTEM] Date/time of report: [DATE] [TIME] Patient: [PT IDENTIFIER PER POLICY], room [ROOM] Reported by: [YOUR NAME, CREDENTIALS]

Facts observed:

  • Per MAR, [DRUG] [DOSE] documented at [TIMES] on [DATE].
  • Pain scores recorded after those doses: [SCORES WITH TIMES]. [OR: No reassessment documented after doses at TIMES.]
  • Pt reported to me at [TIME] that [WHAT PT SAID ABOUT DOSES RECEIVED OR RELIEF].
  • [ANY COUNT / WASTE / DISPENSING CABINET DISCREPANCY, stated as numbers and times only.]

Actions taken: [PRESCRIBER NAME] notified at [TIME]; charge RN [NAME] notified at [TIME]. I am reporting this so the records can be reviewed. I am not drawing a conclusion about the cause. ```

If you remember one thing

Chart the dose, the pain score after it and who you told, each with a time. The record will show the pattern on its own, and you won't have to accuse anyone.

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.

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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