shift is wild

How a note is read

Your note should not stop at the intervention

Show what happened after the intervention, what you checked, and what care followed—with examples that connect the dots.

6 min read built on 6 full opinions updated 2026-09-13

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

Maya reacting to this topic

You gave the medication, repositioned the patient, or helped them walk. What happened next? At reassessment, chart what changed, what did not, whether anything new appeared, and what care followed.

The short version

  • Tie the reassessment to the intervention. Say when you reassessed and which earlier action you were checking.
  • Compare before and after. Include what the patient reported and what you found, not just your conclusion that treatment worked.
  • Look for new problems. Symptom relief and an unwanted effect can happen together.
  • Show the next step. Chart additional care, who you notified, the response, and the next reassessment or handoff.
  • Say when you do not know the outcome. If the patient declines reassessment or you cannot complete it, document why and how you plan to follow up.

What goes wrong

The most common mistake is stopping at the task: medication given, dressing changed, patient repositioned.

That tells the next nurse what happened to the patient. It does not tell them what happened afterward. The medication administration record may show that you gave a dose without showing whether the symptom improved or a new concern appeared.

Vague wording does not fill that gap. Effective is a conclusion without the findings. Tolerated well tells you nothing about what was checked. And a lower pain score is only part of the response if the patient also became unusually drowsy.

Connect three things in your reassessment: the patient’s current condition, the response to the intervention, and the care that followed. Needed another intervention? Follow up on that one, too.

It is not hypothetical

Estate of Guillotte ex rel. Jordan v. Delta Health Group, Inc., Mississippi Supreme Court, 2009.

The opinion describes expert testimony about staff reviewing a resident’s weight loss and starting measures, but not adequately following through as the resident’s nutritional condition kept deteriorating. It also discusses expert testimony about gaps in documentation across several areas of care.

The court found summary judgment improper for claims based on individual staff negligence, but proper for the corporate-negligence claims. That was not a final determination of liability.

The point for your charting: starting an intervention is not the same as checking whether it is working. Show the follow-through.

What to write instead

These examples are fictional, not excerpts from patient records. Chart only what you actually assessed, observed, communicated, or did. The times show a sequence, not reassessment intervals to use for every patient. Base your timing on the patient’s condition, applicable orders, and facility policy.

as written

Pain medication effective.

as it holds up

1440: Reassessed after PRN analgesic administered at 1400 per MAR. Patient reports incisional pain decreased from 7/10 to 3/10, meeting stated comfort goal. Able to turn in bed without guarding. Awake and answering questions appropriately; respiratory rate 16/min. Denies nausea or dizziness. Assisted into preferred position. Next pain and sedation reassessment planned for 1515.

as written

Antiemetic given. No relief. Provider aware.

as it holds up

0930: Reassessed after antiemetic administered at 0900 per MAR. Nausea remains 6/10; approximately 100 mL clear emesis since administration. BP 124/76, HR 88; alert. 0935: Lee, NP, notified of persistent nausea, emesis, and reassessment findings. 0938: NP evaluated patient; additional antiemetic ordered and administered at 0945 per MAR. 1015: Nausea 2/10; no further emesis. Tolerated 60 mL water. Next nausea and oral-intake reassessment planned for 1045.

as written

Ambulated with assistance. Tolerated fairly.

as it holds up

1100: Ambulated 20 feet with walker and one-person assist; patient reported new dizziness. Assisted to chair. Seated BP 100/62, HR 96; prewalk seated BP 126/74, HR 80. 1105: Patient reports dizziness resolved while seated; BP 116/70, HR 84. Further walking deferred. 1108: Patel, MD, notified of episode and readings; orthostatic vital signs ordered. 1110: R. Jones, RN, accepted handoff, including current findings, pending orthostatic measurements, and need for reassessment before further ambulation.

as written

Repositioned. Resting comfortably.

as it holds up

1600: Follow-up after repositioning at 1530. Patient declines pain rating and movement assessment, requesting rest. Awake and answering questions; respirations observed at 16/min, even. No grimacing observed at rest. Pain relief not confirmed. Explained purpose of reassessment; patient agrees to another attempt at 1630. Call light within reach.

Here is what makes these entries useful:

  • They compare findings. A change from 7/10 to 3/10 says more than better.
  • They separate reports from observations. The patient reports dizziness. The nurse records the measured blood pressure.
  • They include benefit and safety findings. Choose findings that matter to the intervention. Do not substitute a blanket normal assessment.
  • They keep completed care separate from pending care. If reassessment is still planned, do not chart it as done.

For other interventions, match the outcome you chart to the problem. After teaching, write what the patient could explain or demonstrate. After wound care, include relevant bleeding, drainage, pain, or dressing findings. After helping with intake, record what the patient actually consumed and tolerated.

You do not need to repeat every flowsheet or MAR entry in a narrative. Use the appropriate EHR fields. Add enough context to connect the intervention, the response, and what came next.

If symptoms remain concerning or worsen, be specific about communication: who you contacted, when, what findings you reported, what response you received, and what you did next. No response? Document that and any further escalation. Do not delay needed care to finish the note.

Words that do the damage

The problem is not necessarily the phrase itself. It is using the phrase in place of findings.

Phrase Why it falls short Replace with
EffectiveGives a conclusion without the comparison.Pain decreased from 7/10 to 3/10; able to turn without guarding.
Tolerated wellDoes not identify what was assessed.Walked 30 feet; denied dizziness or dyspnea; gait steady with walker.
Stable / VSSHides the values and relevant change.BP 118/72, HR 82; dizziness resolved while seated.
Resting comfortablyObservation alone does not establish symptom relief.Eyes closed, respirations even; symptom reassessment not yet completed.
Provider awareDoes not show what was communicated or what followed.Name and role, contact time, findings reported, response, and action taken.
Will continue to monitorLeaves the next assessment undefined.Specific symptom or finding to reassess and the planned time or clinical trigger.

What the guidance says

  • Show when care and follow-up happened so the reader can follow the sequence. (Credenza, SimpleNursing)
  • Include the patient’s response. Your charting should help the reader evaluate the intervention, not just see a list of tasks. (OpenStax, SimpleNursing)
  • After you evaluate the response, state the next care step and any needed changes to the plan. (Berxi, Biology Insights)

If you remember one thing

Chart what changed, what new concerns you assessed, and what you did next—not just what you did first.

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.

  • We hopefully aren’t losing patients (that would require its own incident report). We observe. “Pt observed sitting on floor” not “Pt found sitting on floor” ... Most of our charting is done on the fetal monitoring strip software. Maternal Vital signs and entries from the MAR flow over and appear on

    r/nursing on Reddit: What are your documentation do’s and dont’s ? reddit

  • If an RRT happens abruptly, you can write a note documenting what happened and why and your interventions (if you don’t have a standard RRT documentation procedure). Same with anything like a fall, new acute symptoms, etc.

    r/nursing on Reddit: What all do you actually make nurses notes about? reddit

  • (PA so and so notified of X) and what did i do for the patient, PIV interventions etc. I dont charts VS/MEDs (that appear anyways) unless theres pertinent secoundary infomation for example" pt tacky to 120s in setting of endorsing feeling anxious" I put in subsequent notes if theres a chan

    r/nursing on Reddit: Need ED Documenting tips reddit

  • WHAT INTERVENTIONS I HANDED OFF TO RECEIVING. REPORT, BELONGINGS, AND A COPY OF THE CHART GIVEN TO (WHO EVER SIGNED FOR THE PATIENT RN OR HIGHER) Dont double chart. Do identify when you brought something to someone's attention and they ignored you (NO NEW ORDERS). Do detail things you feel are

    r/nursing on Reddit: Nursing notes to cover you a$$? reddit

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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