Orders, handoffs and other people

When the patient tells you what they did

A patient says something that sounds like a crime. What to chart, in whose words, and what to leave for someone else to decide.

8 min read built on 3 full opinions updated 2026-10-11

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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You're in the middle of care and the patient says something that sounds like a crime. They shook the baby. They hit their partner. They drove home drunk. Now you have to decide fast what goes in the chart, and in whose words. The answer is short: chart their exact words, what you saw and what you did next. Nothing else.

Key points

  • Write down what the patient said word for word, inside quotation marks. Add the time and the names of everyone in the room.
  • Chart only what affects care: injuries, intoxication or withdrawal, the patient's safety, and any risk to a child or another person.
  • Keep your verdict out. Don't write admitted, confessed or abuser. Don't guess at what really happened.
  • If a child or anyone else may be at risk, tell your charge nurse this shift and follow your facility's mandated reporter policy. Chart who you told and when.
  • Leave out the rest of the story (old offenses, other people's names, details of a crime) unless it changes what the team does next.

What to write

In these examples the patient's words come after a colon. In your real chart, put them inside quotation marks.

How it gets written How to write it
Pt admitted to abusing her son.1430 During IV start, pt stated, unprompted: I shook him because he wouldn't stop crying. I didn't mean to hurt him. No visitors present. Charge RN J. Smith notified 1440.
Pt confessed to DUI, very remorseful.Pt stated: I had four beers before I drove. Last drink approx 2100 per pt. Pt tearful, A&O x4, speech clear. ETOH level drawn per order.
Mother is an obvious abuser, story doesn't add up.Mother stated child fell from couch onto carpet approx 1900. Findings: 3 oval bruises, approx 1 cm each, R upper arm; 2 cm bruise L cheek. Provider notified 1515. SW consult per policy.
Pt says he's been dealing out of his apartment for years, named his supplier.Pt reports daily IV heroin use, last use approx 0600 today. COWS 9. Provider notified for withdrawal orders.
Pt got defensive and was clearly lying about the bruises.When asked about bruising on L forearm, pt stated: I don't want to talk about that. Pt turned away and did not answer further questions.
Per staff, husband has a record.Leave it out. If the husband said something to you directly: Pt's husband stated to this RN: [his words].

Template

In your real chart, put the patient's words inside quotation marks. The templates leave them out so they copy cleanly.

Chart entry

[DATE] [TIME]
During [CARE ACTIVITY, E.G. DRESSING CHANGE], pt stated, [UNPROMPTED / IN RESPONSE TO QUESTION: WHAT YOU ASKED], word for word:
[EXACT WORDS AS SPOKEN, NOT SUMMARIZED]
Present in room: [NAMES AND ROLES, OR NO ONE ELSE PRESENT].
Pt demeanor: [OBSERVED BEHAVIOR, E.G. TEARFUL, CALM, SPEAKING IN FULL SENTENCES]. Orientation: [A&O STATUS].
Relevant findings: [INJURIES, INTOXICATION SIGNS, OTHER ASSESSMENT FINDINGS, OR NONE OBSERVED].
Safety: [WHERE THE CHILD OR OTHER PERSON IS NOW, IF KNOWN, AND WHO IS WITH THEM, OR UNKNOWN].
Notified: [CHARGE RN NAME] at [TIME]; [PROVIDER NAME] at [TIME]; [SOCIAL WORK OR OTHER PER POLICY] at [TIME].
Report per facility policy: [MADE BY NAME AT TIME / PENDING, ASSIGNED TO NAME].
[YOUR NAME, CREDENTIALS]

Message to your charge nurse

[CHARGE RN NAME], I need to flag something from room [ROOM NUMBER] this shift.
At [TIME], during [CARE ACTIVITY], [PATIENT NAME / MRN] made a statement that may involve risk to [A CHILD / ANOTHER PERSON / THE PATIENT].
The exact words are charted in my note at [TIME].
Present at the time: [NAMES AND ROLES, OR NO ONE ELSE].
What I know about current safety: [WHERE THE PERSON AT RISK IS NOW, OR UNKNOWN].
I have notified [PROVIDER NAME] at [TIME].
Please advise on next steps under our mandated reporter policy. I am available until [END OF SHIFT TIME] at [EXTENSION].
[YOUR NAME, CREDENTIALS]

Record of a report call (if you or your team make one)

[DATE] [TIME]
Report made to: [AGENCY NAME] by phone / online at [NUMBER OR PORTAL].
Made by: [NAME, CREDENTIALS], with [OTHER STAFF PRESENT, OR NONE].
Intake worker: [NAME OR ID]. Reference number: [NUMBER].
Information given: pt statement as charted at [TIME]; findings as charted at [TIME]; current location of [CHILD / PERSON] as known: [LOCATION OR UNKNOWN].
Instructions received from agency: [WHAT THEY SAID TO DO, OR NONE].
Charge RN [NAME] and provider [NAME] informed of report at [TIME].
[YOUR NAME, CREDENTIALS]

Words to avoid

Word or phrase Why it hurts Use instead
admitted, confessedImplies guilt, and guilt is a legal findingstated, reported, plus the exact words
abuse, assault, rape, DV (as your conclusion)It's a label for someone else to decide. You didn't observe itDescribe the injury and record what was said
abuser, perpetrator, suspectLabels a personThe role: pt's mother, visitor identified by pt as boyfriend
claims, alleges, allegedlyTells the reader you don't believe the patientstated
remorseful, guilty, manipulative, lyingMind readingWhat you saw: tearful, avoided eye contact, declined to answer
inappropriateSays nothing specificWhat exactly happened, and when
story doesn't add upYour inferenceEach account with its source and time

Your own conclusion in place of exact words

The usual mistake is to summarize in your own words and add a conclusion. Something like Pt admitted to abusing child. That's one line with three problems.

  1. The source is gone. Did the patient say it? A relative? Did the nurse work it out? The reader can't tell. Because it's written as fact, it reads as your own finding.
  2. ***Admitted* and abusing are conclusions.** Whether abuse happened gets decided somewhere else, and the chart isn't that place. Nobody can check a summary against anything. They can check exact words.
  3. You will forget. Charts get pulled for hearings, often years later. Nurses on r/nursing who got subpoenaed keep saying the same thing: they remembered that it happened, but the wording was gone. What you write now is what you'll have then.

The opposite mistake is charting everything: the whole story of the fight, the dealer's name, the patient's record from ten years back. None of it helps the next nurse care for this patient. And all of it sits in a legal record that anyone with a subpoena can read.

The test is simple. Does this change what the team does for the patient, or for someone who may be at risk? If yes, chart it. If no, leave it out.

One more trap. You're not the investigator. Ask what care needs: Is the child safe right now? Where is the child? Are you hurt? Skip the detective questions about how and why.

Bottom line

Chart their words with the time, what you saw and what you did. Leave out anything you guessed.

Official guidance

  • Record the patient's own words and make it clear the patient is the source. A reader should never have to guess who said what. (NursingCenter, ATrain Education)
  • Chart facts and observations: what you saw, heard and did. Leave out opinions, conclusions and remarks about the patient's character. (NSO, OpenStax)

In court, 1980–2012

What happened in 3 court cases

None of these three cases involves a patient confessing a crime to a nurse. What they show is what happens to nursing notes afterward. A court reads them, often years later, for a reason the nurse never saw coming.

Roberson v. Provident House: Louisiana Court of Appeal, 1990. A quadriplegic nursing home resident sued over an indwelling catheter. He said he begged the nurse not to put it in. The nursing notes said something else. According to them, the external catheter was stopped because of irritation and because it wasn't working, and the family had called asking for the internal catheter to come out. One summary described his sister as having over-reacted. The court said some entries were almost illegible. The nurses never told their side in person: "No nurse testified." The notes were the only voice they had. That included one line of opinion about a family member, and the court read it along with everything else.

Lingham v. Harmon: District Court, D. Maryland, 1980. This was a fight over who got a life insurance payout. It had nothing to do with the quality of nursing care. The court had to work out what a dying patient wanted and how her mother behaved, and it relied partly on the nursing notes to do that. Those notes had the patient's own words with times, plus what her mother told the nurse about her. The court wrote: "This attitude on the part of Mrs. Lingham was corroborated by the nurse’s notes which have been cited above." A nurse's exact, timed words helped decide a case that had nothing to do with that nurse.

State v. Robinson: Ohio Court of Appeals, 2012. This was a criminal trial, and the patient was the alleged victim. On the stand she was questioned about what she told hospital staff, when she said it and who was in the room: "She had told the nurse at 7:45 a.m. that she remembered nothing about the night before". Her father was there at the time. By 8:55 a.m. she remembered doing shots. The lawyers compared these timed statements line by line. It's normal for a patient's account to change from one hour to the next. Your job is to get each version down accurately, with the time and who was present.

Court decisions

Published decisions, linked to CourtListener.

All decisions behind this guide

From nurses online

Quoted as written. Opinion, not a source.

  • Secondly, chart only enough so that: a) it shows you truly assessed the patient b) followed orders c) provided some nursing care/judgement/care plan d) and have enough detail for you to remember the patient/event so that, if all you are handed in a court case is your notes, you will be able to hones

    r/nursing on Reddit: “Document/chart like you’re going to court” reddit

  • Ah, I understand better now. This is a criminal case against the patient. Ok, that advice is probably not necessary then. ... Just because you have been subpoenaed to testify does not mean you have to testify. You only have to show up. And I’m not even sure you are legally allowed to testify conside

    r/nursing on Reddit: Looking for advice about a subpoena to testify against a patient reddit

  • Contact the hospitals legal team asap. I was subpoenaed about an incident that happened YEARS ago. I remembered it but not exact wording and details from the charting. The hospitals lawyers pulled the chart and helped me step by step with everything required of me that was related to the case.

    Received subpoena. Need advice : r/nursing reddit

  • This is a pretty normal part of forensic nursing for SA and DV. The attorneys summoning you should give you access to the chart notes as well so you can speak to your charting and what you saw/documented about this patient.

    r/nursing on Reddit: Summoned to testify in court, I could use some advice reddit

Other guides

Advice, not law.