shift is wild

Orders, handoffs and other people

The patient who came in with an officer

The officer's version, your assessment and the cuffs: how to chart a patient in custody so the record still shows who said what.

8 min read built on 6 full opinions updated 2026-10-01

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

Denise reacting to this topic
All 11 sections

Your patient rolls in cuffed. A deputy, a corrections officer or two ICE agents take the chair by the door. Over the shift the officer will tell you things, someone will adjust the restraints, and the hold may get lifted or changed. All of it goes in the chart. Write it as what you saw and who told you what. Leave your conclusions out.

The short version

  • Name the custody. Agency, officer's name, badge number, time of arrival. Also note whether they stay at the bedside or step out.
  • Chart the restraints like any other device. Type, limb, who put it on, who has the key. Skin and circulation checks, with times. Every time the restraints come off for care and go back on, chart that too.
  • Attribute what the officer says. It's the officer's account. It goes in as theirs, not as your assessment.
  • Chart custody changes when they happen. Hold lifted, transferred or added? Write who told you, what time, and whom you notified.
  • Keep your assessment separate. What you see stays in your words, even when the officer sees it differently.

What to write instead

How it often gets charted How it reads better
Pt in police custody.Pt arrived 1415 accompanied by [AGENCY] Officer J. Ruiz, badge 4471. Officer states pt is under arrest. Officer remains at bedside.
Pt shackled.L ankle cuffed to bed rail by Officer Ruiz at 1420. Officer holds key. L foot warm, pink, cap refill <3 sec, pedal pulse palpable, pt denies numbness. Skin intact at cuff site.
Pt combative during arrest, hit head on pavement.Per Officer Ruiz, pt struggled during arrest and struck head on pavement. Pt states he was pushed. 3 cm abrasion R forehead, no active bleeding. GCS 15. Dr. Patel notified 1430.
Pt faking sx, officer agrees.Pt reports he cannot stand. Attempted to stand with 2 assist at 1810, legs buckled, returned to bed. Officer at bedside states he believes pt is exaggerating. Dr. Patel notified of inability to bear weight 1815.
Hold dropped.1630 Officer Ruiz informed this RN that [AGENCY] is releasing custody; no charges at this time per officer. Ankle cuff removed by Officer Ruiz 1632. Officer left unit 1635. Charge RN M. Lee notified 1636.
ICE here.1100 two individuals identifying as ICE officers, names/badges D. Ward #2210 and K. Shaw #1987, arrived at bedside and stated pt is in ICE custody. Charge RN and house supervisor notified 1102 per hospital policy.
Exam done, officer present.Abdominal and GU exam at 1500. Officer Ruiz remained in room during exam; RN requested privacy, officer declined citing agency policy. Pt informed officer was present.

Copy this

Arrival in custody (chart note)

`` [DATE] [TIME] Pt arrived via [EMS / AGENCY VEHICLE / WALK-IN] accompanied by [AGENCY NAME] Officer [NAME], badge [NUMBER]. Second officer: [NAME, BADGE / NONE]. Per Officer [NAME], pt is [UNDER ARREST / IN CORRECTIONAL CUSTODY / IN ICE CUSTODY / OTHER AS STATED BY OFFICER]. Custodial restraints on arrival: [TYPE, e.g. metal handcuff / leg shackle] on [LIMB], secured to [BED RAIL / OTHER LIMB / NONE]. Applied by [AGENCY]. Key held by Officer [NAME]. Restraint site check [TIME]: skin [INTACT / FINDINGS], color [ ], temp [ ], cap refill [ ], pulse distal to restraint [ ], pt reports [NUMBNESS / PAIN / NONE]. Officer statements regarding events prior to arrival: Per Officer [NAME], [WHAT OFFICER SAID, IN OFFICER'S TERMS]. Pt statement regarding same: Pt states [WHAT PT SAID / PT DECLINED TO DISCUSS]. RN assessment: [YOUR FINDINGS]. Officer location: [AT BEDSIDE / OUTSIDE DOOR / OTHER]. Provider [NAME] notified [TIME]. Charge RN [NAME] notified [TIME]. ``

Restraint removed or reapplied, or officer present for care (chart note)

`` [DATE] [TIME] Custodial [TYPE] on [LIMB] removed by Officer [NAME], badge [NUMBER], for [PROCEDURE / AMBULATION / TOILETING / IMAGING]. Reapplied [TIME] by Officer [NAME] to [LIMB]. Site check after reapplication: skin [ ], color [ ], cap refill [ ], pulse [ ], pt reports [ ]. Officer [NAME] [REMAINED IN ROOM / STEPPED OUT] during [EXAM / PROCEDURE]. Privacy requested by [RN / PROVIDER / PT]: [YES / NO]. Officer response: [WHAT OFFICER SAID OR DID]. Pt informed of officer presence: [YES / NO]. ``

Custody status change (chart note)

`` [DATE] [TIME] Officer [NAME], badge [NUMBER], [AGENCY], informed this RN that [CUSTODY RELEASED / TRANSFERRED TO AGENCY NAME / NEW HOLD PLACED BY AGENCY NAME]. Reason as stated by officer: [REASON / NOT STATED]. Documents presented: [DOCUMENT TYPE / NONE]. Copy [PLACED IN CHART / GIVEN TO SECURITY / NOT PROVIDED]. Custodial restraints [REMOVED BY NAME AT TIME / REMAIN IN PLACE]. Officer(s) [LEFT UNIT AT TIME / REMAIN AT BEDSIDE]. New officer(s) if any: [NAME, BADGE, AGENCY, TIME ARRIVED]. Pt informed by [OFFICER / RN / PROVIDER] at [TIME]. Pt response: [ ]. Notified: Charge RN [NAME] [TIME], provider [NAME] [TIME], house supervisor / security [NAME] [TIME]. ``

Message to charge nurse or house supervisor

`` [TIME] — Room [NUMBER], pt [INITIALS / MRN]. Custody status update: [AGENCY] Officer [NAME], badge [NUMBER], states [WHAT CHANGED]. Effective [TIME]. Current restraints: [TYPE AND LIMB / NONE]. Officer(s) present: [NAMES, AGENCY / NONE]. Requested of officer: [e.g. step out for exam / copy of hold document]. Officer response: [ ]. Clinical status unchanged / changed: [BRIEF]. Need from you: [POLICY GUIDANCE / SECURITY / NOTHING, FYI]. — [YOUR NAME], RN ``

Words that do the damage

Word or phrase Why Use instead
combative, aggressiveA label. Doesn't say what happened or who saw it.The behavior itself, with the source: per officer, pt kicked, or what you saw: pt swung R arm toward RN
faking, malingering, drug-seekingA conclusion, and often somebody else'sWhat the patient reported and what you observed, side by side
restrained (alone)Medical or custodial? Which limb? Who put it on?custodial handcuff R wrist to rail, applied by [AGENCY]
inmate, prisoner, criminalA legal claim you can't verifypt in custody of [AGENCY] per Officer [NAME]
police saidWhich officer? Which agency?Officer name, badge number, agency
hold (alone)Whose hold, since when, on what authority?[AGENCY] hold per Officer [NAME], [TIME]
tolerated well, stable for d/cTemplate language that can contradict what you sawActual gait, mental status and ability to transfer at discharge

If you remember one thing

Write down who said it, who put the cuffs on, and when anything changed. The officer's account goes in as the officer's. Your assessment stays yours.

What goes wrong

The most common one: the officer's story turns into the patient's history. He tells you the patient was fighting, faking, swallowed something, got hurt during the arrest. You type it in as plain fact. It's easy to do. But once it sits in the chart with no name on it, anyone reading later takes it as a clinical observation by staff. Nobody can see anymore that it came secondhand, from someone who isn't a clinician and may care a lot about how the event gets described.

The second is the reverse. The custody details never make it in. No cuffs, no mention of who was in the room for the exam, nothing about when the hold ended. Later someone needs to know if the patient was in custody, under whose authority, and with what restraints. Billing might ask. A court might. So might the next shift. With a blank there, everyone rebuilds it from memory.

The third: a discharge note that doesn't match the bedside. The template says stable. The patient can't stand on his own.

What the guidance says

  • An officer at the bedside cuts into the patient's confidentiality during care. So whether the officer stayed, and whether anyone asked for privacy, is part of the clinical picture. (PMC, Taylor & Francis)
  • Shackling patients in custody should follow clear, written facility procedures. Know your policy. Chart against it. (PMC, APHA)
  • If it's not on your facility's approved abbreviation list, spell it out. An agency acronym or shorthand for a hold type can mean different things to different readers. (Berxi, nurse.com)

It is not hypothetical

What happened in 5 court cases — tap to read

Smith v. Eovaldi, U.S. District Court, S.D. Illinois, 2015. CourtListener This was an early screening order on an inmate's complaint, so everything below is what the plaintiff alleged. No court made findings about it. Per the complaint, an officer told the clinician the inmate had smeared feces on himself. The inmate said it happened during a beating. The opinion recounts that "Dr. Delong noted in the medical record that Smith had spread fecal matter on himself". The clinician wasn't a defendant. The chart entry still landed in the middle of the dispute, carrying one side's version with no attribution.

Estate of James Franklin Perry v. Wenzel, U.S. Court of Appeals for the Seventh Circuit, 2017. CourtListener The court reversed a summary judgment, so it read the facts in the plaintiff's favor. Two officers stayed with a patient in custody through ED treatment for seizures. The opinion says his medical record called him "alert and appropriate upon [discharge]". The officers said he couldn't walk by himself and had to be helped into a wheelchair. One officer also said a nurse told him the patient was faking. Two stories, then: one in the chart, one from the bedside. Both got picked apart afterward.

University of Kansas Hospital Authority v. Board of Commissioners, Supreme Court of Kansas, 2014. CourtListener The hospital sued a county to pay for a patient's care, arguing he'd been in the sheriff's custody. The court said the county didn't have to pay: the man was not a prisoner committed to or held in the county jail when he was injured and hospitalized. Part of what the court leaned on was what the medical record said about holds. The only police hold in it was from ICE. The court also noted: "While Contreras was in the hospital, there were no guards placed outside his room, and he was not handcuffed or restrained in any way." What the chart said about guards, restraints and holds helped decide who had custody.

State v. Garrison, Connecticut Appellate Court, 2022. CourtListener Police questioned a patient on an IV in an ED room for hours. No Miranda warnings. Hospital security and medical staff were in the room for part of it. The appellate court held he was in custody, and one of the coercive pressures it listed was "the restraint the medical attendants imposed on him for purposes of his treatment, and of which the police took advantage". Who was in the room, how long, what kept the patient in bed: all of it mattered. And often you're the only one writing those things down as they happen.

Pool v. Ohio Dept. of Rehab. & Corr., Ohio Court of Claims, 2017. CourtListener An inmate testified he reported shoulder and back pain after a use-of-force incident, "as documented in a nursing assessment form". The form became a trial exhibit. Routine nursing notes on patients in custody end up in court. This one did.

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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