Nursing documentation · one-page reference

Words to avoid in a nursing note — and what to write instead

Write what you observed, what you did, and what happened next. Don't let the wording claim more than you know.

Instead of	Why it reads badly later	Write
Fine; stable	Does not say what you assessed or compared	Relevant findings, measurements, symptoms, and time
Noncompliant	Turns a specific decision into a label for the patient	Care offered, care declined, stated reason, and response
Demanding; rude; drug-seeking	Can mix what you observed with judgment or an assumed motive	Specific requests, behavior, symptoms, and nursing actions
Will continue to monitor	Says what you intend to do, not what you observed	A specific plan plus actual reassessment entries
Provider aware	Does not say what communication happened	Name, time, information communicated, and response
Understands	Does not show how you checked understanding	Teach-back, demonstration, or the patient’s stated plan
Always; never; at all times	Claims more than one observation can establish	Defined times, periods, and accurately documented coverage
Tolerated well	Leaves the patient's response unclear	Pain, symptoms, relevant findings, and assistance needed

Before and after

Instead ofPatient fine.

Write0100—Awake; answers questions appropriately. Respirations 16/min and unlabored. Denies shortness of breath.

Instead ofMD aware.

Write1410—Paged Dr. Lee regarding urine output of 20 mL over past 2 hours. Separate later entry: 1420—Spoke with Dr. Lee; reported urine output and BP 118/70. No new orders received.

Instead ofPatient understands instructions.

Write1100—Reviewed call-light use and need for assistance before standing. Patient demonstrated call-light use and stated plan to call before getting out of bed.

Instead ofTolerated dressing change well.

Write1030—Dressing change completed. Patient rated pain 3/10 before procedure and 4/10 afterward. No bleeding observed during dressing change.