Any note: how it gets read

When to use the patient's exact words

Quote marks mean the patient's exact words. When someone reads your chart years later, those words carry the note.

8 min read built on 5 full opinions updated 2026-10-07

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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A patient tells you something that matters. They refuse a test, threaten someone, describe their pain, or explain how they fell. You can chart what they said, or you can chart your summary of it. Years later someone reads that chart line by line, and those two notes look very different.

Key points

  • Quote word for word when the words themselves matter. That means refusals, threats, anything about self-harm, how an injury happened, answers about drugs or alcohol, and symptoms in the patient's own terms.
  • Quotation marks go only around what the patient actually said. If you didn't catch the exact words, write Pt reports... and leave the marks off.
  • Don't clean anything up. Profanity goes in as spoken.
  • For a refusal, chart three things: what you told the patient, what they said back, and who you notified.
  • Never use quote marks to show doubt (scare quotes). If you write Pt reports and then put the word pain in quote marks, it reads as sarcasm to anyone who opens the chart.

What to write

In the examples below, single quote marks stand in for the regular quotation marks you'd type in the real chart.

How it often gets charted What holds up better
Pt refused ER transfer.Per Dr. Lee, advised pt to go to ED now for troponin and monitoring. Explained chest pain may be a heart attack and can be fatal. Pt states, 'I can't, I have to get my kids. I'll come back tomorrow.' Pt repeated back that she could die. Dr. Lee notified 1420.
Pt verbally abusive to staff.Pt shouted, 'Get the hell out of my room or I'll throw this at you,' while holding water pitcher overhead. RN left room. Charge RN notified 2215.
Pt c/o pain 7/10.Pt rates pain 7/10, states 'it's like a knife under my ribs when I breathe in.' Points to R lower ribs.
Pt denies drug use.Asked about drug/alcohol use in past 72 hrs. Pt states, 'Just weed and a couple beers, nothing in two days.' UDS sent 0815.
Resident noncompliant with bathing.Offered shower 1900 per care plan. Resident states, 'Not tonight, I'm too tired.' Re-offered 2000, declined again. Feet not visualized. Charge RN notified 2010, son to be called in AM.
Pt anxious, wants to leave.Pt standing at window, states, 'If you don't let me go home I'll jump out of here.' 1:1 sitter initiated 0340, Dr. Patel paged 0342.
Pt fell, unwitnessed.Found pt on floor beside bed 0610. Pt states, 'I got up to answer the phone and my legs gave out.' Denies hitting head.

Look at the first row. The quote by itself isn't enough. The right-hand version shows what the patient was told, what she said back, and who was notified. In Weber the decline itself was charted. The details of the conversation weren't.

Template

Wherever a template says EXACT WORDS, type what the patient said inside regular quotation marks.

[DATE] [TIME]. Per [PROVIDER NAME], advised pt to [RECOMMENDED CARE, e.g. go to ED now for troponin and cardiac monitoring].
Explained reason: [WHAT YOU SAID ABOUT THE RISK, e.g. symptoms may be a heart attack; delay can cause permanent heart damage or death].
Pt states: [EXACT WORDS, IN QUOTATION MARKS].
Pt asked to repeat back the risk. Pt states: [EXACT WORDS, IN QUOTATION MARKS].
Alternatives offered: [WHAT ELSE WAS OFFERED].
[PROVIDER NAME] notified at [TIME]. Response: [WHAT PROVIDER SAID OR ORDERED].
Pt given [WRITTEN INSTRUCTIONS / RETURN PRECAUTIONS] and told to call 911 if [SYMPTOMS].
[YOUR NAME, CREDENTIALS]

Threat or verbal aggression

[DATE] [TIME]. In room [ROOM NUMBER] during [WHAT YOU WERE DOING, e.g. scheduled med pass].
Pt states to this RN: [EXACT WORDS, IN QUOTATION MARKS, NOT CENSORED].
Pt observed: [WHAT PT DID, e.g. standing at bedside, holding water pitcher overhead, voice raised].
Action: [WHAT YOU DID, e.g. stepped out of room, called for second staff member].
[CHARGE RN / PROVIDER / SECURITY] notified at [TIME].
Pt status at [TIME]: [WHAT YOU SAW, e.g. seated in bed, speaking at normal volume].
[YOUR NAME, CREDENTIALS]

Patient's account of a fall or injury

[DATE] [TIME]. Pt found [LOCATION AND POSITION, e.g. on floor beside bed, lying on L side].
Asked pt what happened. Pt states: [EXACT WORDS, IN QUOTATION MARKS].
Pt states regarding head strike / pain: [EXACT WORDS, IN QUOTATION MARKS].
Assessment: [VS, NEURO CHECK, INJURIES SEEN, WITH LOCATION AND SIZE].
[PROVIDER NAME] notified at [TIME]. Orders: [ORDERS RECEIVED].
[FAMILY MEMBER NAME / RELATIONSHIP] notified at [TIME].
[YOUR NAME, CREDENTIALS]

Statement you didn't catch word for word

[DATE] [TIME]. Pt reports [YOUR SUMMARY, NO QUOTATION MARKS].
Exact wording not recorded at time of statement.
[YOUR NAME, CREDENTIALS]

Words to avoid

Word or phrase Why it causes trouble Use instead
refused (alone)Shows the outcome, not the conversationWhat you advised + the pt's words + who you notified
noncompliantIt's a judgment and says nothing about what happenedWhat was offered, when, and what the pt said
abusive, combativeCould mean anything from one curse to an assaultThe exact words and what the pt physically did
claims, allegesSounds like you don't believe the patientstates, reports
drug-seekingA conclusion nobody can checkRequests made, in the pt's words, plus times
educated ptDoesn't show what was taught or whether it landedWhat you explained + the pt's teach-back
scare quotes around a single wordReads as sarcasmNo marks, or quote the whole sentence
censored profanity (f\\\*)You changed the words but kept the quote marksThe words as spoken, or a summary with no marks

A label where the words should be

The most common mistake is writing a label where the words should be. Refused, noncompliant, abusive, combative, anxious: every one of those is a conclusion. Write one and the chart keeps your conclusion but loses the facts behind it.

Later that causes trouble, and the reason is simple. A reader can check facts. They can't check a label. Pt refused ER doesn't tell anyone whether the patient heard that the chest pain could be a heart attack, or only heard that the doctor wanted labs. Verbally abusive could mean a death threat. Or one swear word. The patient may not remember. You won't either. The only thing anyone can still read is what you wrote at 1430 that day.

The second mistake is the opposite one: quote marks around a paraphrase. A reader takes anything in quotation marks as the patient's exact words. A tidied-up version in quote marks is less trustworthy than an honest summary with no marks at all.

Bottom line

Quotation marks mean the patient's exact words. When the words matter, write them down exactly. Then add what you told the patient and who you called.

Official guidance

In court, 2017–2024

What happened in 5 court cases

Weber v. Sharma: Appellate Division of the Supreme Court of the State of New York, 2024. A woman came to a clinic with chest pressure and arm pain. She went home and died that night of a heart attack. The cardiologist's record said she declined transfer to the ER for troponin testing. The nurse testified that she told the patient to follow the doctor's advice and go to the emergency department, and her chart notes said the same. The court held that the nurse's notes were admissible. On that motion the doctors couldn't use their own accounts of what they told the patient, so the records and the nurse's testimony had to carry that part of the case. The trouble was what the records left out. They showed the refusal. They didn't show what she'd been told about how serious her condition might be. In the court's words, "nor do the medical records reflect any such detailed discussion." The court sent the claims against the cardiologist and the practice back for further proceedings.

State v. Jones: Supreme Judicial Court of Maine, 2019. A SAFE nurse wrote down the patient's answers while taking history for the exam. At trial the court admitted the part of her report tied to treatment, including what the patient said about how her neck got bruised. It kept out the section where the nurse had "transcribed-apparently verbatim-the victim's extensive account of the incident." The appellate court affirmed. So the court treated the two differently: the patient's words recorded for care, and the long free-standing narrative.

Henderson v. State: Court of Criminal Appeals of Alabama, 2017. During a routine intake assessment, a jail nurse asked a new inmate about drug use. He said he used only marijuana and alcohol, and nothing in the last two days. His urine came back positive for methamphetamine. The nurse testified about both, the answer and the result, in a capital murder trial. The intake question took her thirty seconds, and it became evidence.

Manter v. CPF Senior Living – Northgate Park L.L.C.: Ohio Court of Appeals, 2024. An assisted-living resident had a foot ulcer and later lost his leg. He admitted he had probably refused baths, but he remembered very little of his time there. The facility had no nursing notes for about seven months and no record of his bathing schedule. The executive director agreed that if he wasn't complying with bathing, "that was something she would expect to see in the nursing notes." The appeals court found genuine factual disputes over what care he needed and what he actually got. Maybe the refusals happened. Nothing in the chart showed them.

Rucigay v. Wyckoff Hgts. Med. Ctr.: Appellate Division of the Supreme Court of the State of New York, 2021. This was a fall case. Two nursing notes with the patient's own statements were first kept out, then read to the jury without objection. If a patient says something to you and you write it down, it can end up being read aloud in a courtroom.

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.