When something goes wrong with a patient or a med

The postpartum mood screen came back positive. now what goes in the chart

Charting the number takes four seconds. What you write after it decides whether the next shift, and maybe a judge, can act on it.

8 min read built on 5 full opinions updated 2026-10-12

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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She fills out the EPDS or the PHQ-9, and the total comes in over your unit's cutoff. Or the score is fine, but during the fundal check she says something about herself or the baby that sticks with you. Entering the number takes four seconds. Whatever you write next decides whether the next nurse, the provider and social work can actually act on it.

Key points

  • Chart the tool, the total, and the self-harm item on its own line. A 9 with a positive item 10 matters more than a 15 with a zero there.
  • Write down what she said in her own words, marked as verbatim the way your facility does it. Don't turn it into a diagnosis.
  • Chart the safety question you asked and her answer, word for word.
  • Chart who you told, when, what they said back, and what happened next: who stayed with her, the referral, social work, the plan.
  • Describe what she did with the baby. Skip the adjectives about what kind of mother she is.

What to write

How it often gets charted What works better
EPDS 14. Provider aware.EPDS completed 1430, total 14. Item 10 (self-harm) scored 0. Highest items: 3, 4, 7 (self-blame, anxiety, sleep). Dr. Patel notified by phone 1445, results reviewed. Plan: SW consult today, outpatient referral before d/c.
Pt tearful, seems depressed.Pt tearful during assessment, crying ~10 min. In her words (verbatim): I keep thinking everyone would be better off if someone else raised him. Asked directly about thoughts of harming self: pt states no. Asked about thoughts of harming baby: pt states no, states she is scared because the thought came out.
Denies SI.Asked: Are you having any thoughts of hurting yourself or ending your life? Pt answered: No, I'm just so tired. No plan, no prior attempts per pt.
Poor bonding.Infant crying in bassinet ~15 min during my time in room; pt watched, did not pick up. When asked, pt said she was afraid she would drop him. Assisted with holding; pt held infant 10 min with support, made eye contact, spoke to him.
Pt refused SW.SW consult offered 1600. Pt declined, stating she does not want anyone thinking she can't take care of her baby. Explained SW role. Pt agreed to receive written resources. Dr. Patel informed of decline 1610.
Will continue to monitor.Partner at bedside, aware of plan. Rechecked 1800: pt resting, ate dinner, states she feels a little better after talking. Reported to oncoming RN Lee at 1900, including screen result and SW plan.

Template

Wherever you see verbatim below, use your facility's convention for marking a patient's exact words.

Positive screen, safety questions negative

[DATE] [TIME]
Postpartum mood screen: [EPDS / PHQ-9] completed by pt at [TIME].
Total score: [SCORE] (unit cutoff [CUTOFF]).
Self-harm item ([ITEM NUMBER]) scored: [0 / 1 / 2 / 3].
Highest-scoring items: [ITEM NUMBERS AND TOPICS, E.G. SLEEP, ANXIETY, SELF-BLAME].
Pt statement, verbatim: [EXACT WORDS, IF ANY].
Asked directly: [QUESTION ASKED ABOUT HARMING SELF]. Pt answered: [HER ANSWER].
Asked directly: [QUESTION ASKED ABOUT HARMING BABY]. Pt answered: [HER ANSWER].
Observed: [AFFECT, CRYING, SLEEP, EATING, INTERACTION WITH INFANT, IN FACTS].
Support present: [WHO IS AT BEDSIDE / AT HOME, PER PT].
Notified [PROVIDER NAME, ROLE] at [TIME] by [PHONE / IN PERSON / PAGE].
Provider response: [WHAT THEY SAID / ORDERED].
Plan: [SW CONSULT / REFERRAL / RESCREEN / RESOURCES GIVEN].
Pt informed of plan at [TIME]. Pt response: [AGREED / DECLINED + HER REASON].
Reported to oncoming RN [NAME] at [TIME].

Self-harm item positive, or a troubling statement about herself or the baby

[DATE] [TIME]
[WHAT HAPPENED, E.G. EPDS ITEM 10 SCORED 2 / PT MADE STATEMENT DURING CARE].
Pt statement, verbatim: [EXACT WORDS].
Context: [WHAT WAS GOING ON WHEN SHE SAID IT].
Asked directly: [QUESTION ABOUT THOUGHTS OF HARMING SELF]. Pt answered: [ANSWER].
Asked about plan, means, prior attempts: [QUESTIONS AND ANSWERS].
Asked directly: [QUESTION ABOUT THOUGHTS OF HARMING BABY]. Pt answered: [ANSWER].
Observed: [BEHAVIOR, AFFECT, INFANT CARE OBSERVED, IN FACTS].
Infant location and who is with infant: [BASSINET AT BEDSIDE / NURSERY / WITH PARTNER].
Immediate steps per unit protocol: [E.G. STAFF REMAINED WITH PT, SAFETY CHECK OF ROOM].
Notified [PROVIDER NAME] at [TIME] by [METHOD]. Response: [ORDERS / PLAN].
Notified [CHARGE RN / SW / BEHAVIORAL HEALTH NAME] at [TIME]. Response: [PLAN].
Pt informed of plan at [TIME]. Pt response: [HER WORDS OR ACTION].
Reassessed at [TIME]: [FINDINGS].
Reported to oncoming RN [NAME] at [TIME].

Message to the provider (SBAR)

S: [PT NAME], [ROOM], [PP DAY], positive postpartum mood screen at [TIME].
B: [G/P], [DELIVERY TYPE], [RELEVANT HISTORY PER CHART OR PT, E.G. PRIOR DEPRESSION].
A: [TOOL] total [SCORE]. Self-harm item [SCORE]. Pt stated, verbatim: [EXACT WORDS].
   Asked about harming self: [ANSWER]. Asked about harming baby: [ANSWER].
   Observed: [KEY FACTS]. Support at bedside: [WHO].
R: Requesting [EVALUATION / SW CONSULT / BEHAVIORAL HEALTH CONSULT / ORDERS] by [TIME].
   Please call back at [EXTENSION].

Words to avoid

Word or phrase Why it's a problem Use instead
poor bonding / not bondingA verdict with no behavior behind itWhat she did with the baby, for how long, what she said about it
appears depressedA diagnosis you're not in a position to makeThe score, her words, crying, sleep, eating, eye contact
denies SIDoesn't show you actually askedThe question you asked and her answer
refusedSounds defiant, gives no reasondeclined plus her stated reason
provider awareWho? When? What was decided?Name, time, method, response, plan
bizarre, odd, inappropriateNobody reading it can picture anythingExactly what she said or did
mood WNL, coping wellBuries a positive screen from the same shiftLeave it out, or be specific
overwhelmed, can't copeThat's your conclusion. She didn't say itHer words, marked as verbatim

Provider aware and an opinion with no observation

The usual entry is the score plus one closing line: EPDS 14. Provider aware. Fast. And it leaves every question that matters open.

Nobody reading that line knows which items she scored high on. Or whether item 10 was positive. Or whether you asked her about safety at all. They can't tell what aware means either. Did you call the provider, or did a result land in a queue somewhere? Was there a plan? Did anything happen before discharge? The next shift has to start from zero. A provider deciding on a referral has nothing to work with.

The second mistake runs the other way. You get an opinion with no observation under it: Poor bonding. Flat. Seems overwhelmed, unsure she can care for infant. Each word might come from something real. None of them says what you saw. Later on, a reader can't tell whether poor bonding meant she let a crying baby lie there for twenty minutes, or she was wiped out after a 30-hour labor and asked you to hold him while she ate.

Mood screens and the things mothers say about themselves don't stay in the postpartum stay. They go into referrals and the pediatric chart, and sometimes into records other people read years later. A concrete, fair, specific note protects the mother and the baby. A vague one protects nobody.

Bottom line

The score. Her own words. The question you asked and what she answered. Who you told, and what happened next.

Official guidance

In court, 2015–2026

What happened in 5 court cases

None of these cases involves a nursing note on a mood screen. They're child-welfare cases. In each one, health workers' observations or a mother's own words about postpartum depression got read and retold by a court long after somebody wrote them down.

State ex rel. K.P.: Louisiana Court of Appeal, 2017. A home health nurse came out to weigh the baby. The court's opinion, written four years later, opens with what she saw: a bruise on the older child's forehead, a sippy cup in dog urine, a strong marijuana smell, the mother's slurred speech, the mother nodding off mid-conversation. Sensory facts. No labels. The court affirmed guardianship with the godparents, and the nurse's visit sits at the very start of the record.

In the Interest of M.H. and Z.H.: Texas Court of Appeals, 9th District (Beaumont), 2015. The removal affidavit passed along a conclusion from hospital staff, with no observation attached: "[h]ospital staff feels [Mother] cannot properly meet his needs at this time." The same record shows her history of suicidal ideation and her own report of postpartum depression after both births. The court affirmed termination. So a one-line staff impression can travel a long way past the chart it started in. Make sure it rests on something you saw.

In Re Krystopher C.: Court of Appeals of Tennessee, 2025. An investigator wrote down the mother's own descriptions of her episodes, including her words self-destruct and outrages. The court's findings include this line: "[Mother] admitted having an issue with anger and postpartum depression." The termination rested mostly on other grounds: an infant's malnutrition, domestic violence, drug use. Still, her words about her mood went into the record as hers and came out the other end intact. That's verbatim documentation doing its job. It's also why it has to be accurate.

in the Interest of C.E., a Child: Texas Court of Appeals, 2nd District (Fort Worth), 2023. This mother had prior psychiatric hospitalizations and a disputed bipolar diagnosis. The jury terminated her rights partly on mental-illness grounds. The appeals court reversed, holding that "the evidence does not support a finding that Mother’s mental health conditions rendered her unable to care for Carlo". It also pointed out that records from one of her hospitalizations never made it into evidence. A diagnosis and a history weren't enough. The court wanted evidence of how she actually functioned. Same reason your note should describe function and behavior, and leave the label off.

Adoption of Colton: Massachusetts Appeals Court, 2026. Two voluntary inpatient admissions, 2020 and 2022. The opinion records that "She attributed these admissions to symptoms of postpartum depression" and then weighs her later work with therapy and medication. The court affirmed. Years after the births, someone was still reading her postpartum mood history.

Court decisions

Published decisions, linked to CourtListener.

All decisions behind this guide

From nurses online

Quoted as written. Opinion, not a source.

Other guides

Advice, not law.