Any note: how it gets read

When the score says low risk and you do not believe it

The tool says low risk and the patient in front of you doesn't. How to chart both so the next shift can follow your reasoning.

6 min read built on 0 cases updated 2026-10-19

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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The C-SSRS, Morse or Braden comes back low. The patient in front of you still worries you. You trust what you're seeing and start doing more than the score asks for. Then the chart has to show both things: the score exactly as the tool produced it, and the reasons you went past it.

Key points

  • Record the score the way the tool scores it. Don't change subscale answers to make the total match your concern.
  • Write the specific things you saw or heard that worried you: behaviors, statements, vitals, meds, timing.
  • Write what you did about it: the precaution, the observation level, the equipment, the referral.
  • Write who you told, what time, and what they said.
  • Write when you'll reassess. Then chart that reassessment when you do it.

What to write

Every note follows the same pattern: tool and score as scored, what you saw, what you did, who you told, when you'll look again. If your EHR has a clinical judgment or risk override field, use it. No such field? The narrative note does the job.

C-SSRS screen negative, nurse still concerned

How it gets charted How it should read
C-SSRS negative. Denies SI. Low risk.C-SSRS screen completed 1015, all items answered no, screen negative. Pt answers in one-word replies, flat affect, has not eaten meals today, stated twice my family would be fine without me. Wife died 3 weeks ago per chart. Despite negative screen, RN assesses elevated concern based on above. Belongings checked, cords and razor removed from room. Dr. Patel notified 1030, reviewed above, ordered psych consult and 1:1 observation pending consult. Will rescreen at 1400 and with any change.

Morse low on admission, nurse sees a different patient at night

How it gets charted How it should read
Morse 25. Fall precautions per protocol. Pt resting.Morse rescored 2200: 25, unchanged from admission. POD 2 R hip, hydromorphone 0.5 mg IV given 2130. Since 2100 pt intermittently disoriented to place, attempted to get OOB alone x2, does not recall instructions to call. Pt was oriented x4 on day shift per report. RN assesses fall risk higher than score indicates. Bed alarm on, bed low and locked, call light in hand, moved to room 412 near station. Charge RN M. Lee aware 2215. Night hospitalist paged 2220 re new confusion, callback 2235, orders received for CAM screen and BMP. Will reassess orientation q1h overnight.

Braden in the no-risk range, skin picture says otherwise

How it gets charted How it should read
Braden 19. Skin intact. Turns self.Braden 19 at 0900. Skin intact, sacrum blanchable. Pt has had 3 incontinent episodes since 0600, ate under 25 percent of breakfast and lunch, declined repositioning twice stating too tired. RN assesses pressure injury risk as higher than Braden total reflects. Pressure-redistribution mattress requested from supply 1100, barrier cream applied, turning reminder q2h with pt agreement. Dietitian consult entered 1115 per protocol. Charge RN aware. Will reassess skin and rescore Braden at 2100.

Score is low because the tool was filled in wrong

How it gets charted How it should read
Braden 20, pt mobile.Braden rescored 0800: 15. Previous score of 20 recorded mobility as walks frequently. Pt is bilateral BKA, wheelchair dependent, transfers with assist x1. Activity and mobility subscales corrected on rescore. Prevention measures updated per protocol for current score.

Template

Chart note

[DATE] [TIME]
[TOOL NAME] completed at [TIME]. Score: [SCORE], which falls in the [RISK CATEGORY] range per tool.

Assessment findings not reflected in score:
- [OBSERVATION 1, e.g. behavior, statement in pt's words, vital sign]
- [OBSERVATION 2]
- [RELEVANT CONTEXT, e.g. new med with time given, recent loss, change from prior shift]

Based on the above, RN assesses [FALL / PRESSURE INJURY / SUICIDE] risk as higher than the score indicates.

Interventions initiated:
- [INTERVENTION 1]
- [INTERVENTION 2]
- [INTERVENTION 3]

Notified [NAME, ROLE] at [TIME]. Reviewed score and findings above. Response: [ORDERS RECEIVED / PLAN AGREED / NO NEW ORDERS].
Charge RN [NAME] aware at [TIME].
Plan: reassess [WHAT] at [TIME] and with any change in condition.

Message to the provider (SBAR)

S: Calling about [PATIENT NAME], room [ROOM], re [FALL / SKIN / SUICIDE] risk.
B: Admitted [DATE] for [REASON]. [TOOL NAME] today at [TIME] scored [SCORE], [RISK CATEGORY].
A: My assessment shows higher risk than the score. Findings: [OBSERVATION 1], [OBSERVATION 2], [OBSERVATION 3]. I have started [INTERVENTIONS ALREADY IN PLACE].
R: Requesting [ORDER / CONSULT / OBSERVATION LEVEL / EVALUATION]. Please advise if you want anything else.

Handoff line for the next shift

[TOOL NAME] [SCORE] at [TIME], [RISK CATEGORY] by score. I am treating as higher risk because [MAIN FINDINGS]. In place: [INTERVENTIONS]. [PROVIDER NAME] notified at [TIME], plan is [PLAN]. Reassessment due [TIME].

Words to avoid

Word or phrase Why it hurts Use instead
low risk, no concernsIt speaks for your judgment when your judgment says the oppositeThe score as scored, then your concern and what it's based on
denies SI (standing alone)A denial is one data point. Written alone, it reads like the whole assessmentDenies SI when asked directly plus affect, statements, recent stressors
gut feeling, I just feltYour actual reasoning stays invisibleThe specific observations: attempted OOB alone x2, disoriented to place
appears fine, WNLNobody can check it later. It also hides what you assessedWhat you looked at and what you found
precautions in placeWhich ones? The next shift can't keep them goingName each one: bed alarm on, bed low, room near station
noncompliantJudgmental, and it skips the whyDeclined repositioning x2, stated too tired
MD awareNo name, no time, no responseDr. [NAME] notified [TIME], orders received for ...

A bent score and precautions with no reason

Failure one: the extra precautions have no reason in the chart. The record says Morse 25, low risk. It also shows a bed alarm, a sitter request and hourly rounding. Nothing ties them together. Whoever reads the chart later sees interventions that don't match the documented risk, with no clue why. The next shift may see the low score, decide the alarm is overkill and turn it off.

Failure two: the number gets bent to fit the gut feeling. The nurse thinks the patient is a fall risk, so she scores gait as impaired when it isn't. Or she ticks a secondary diagnosis box that doesn't apply. Now the score isn't a valid result anymore, and it contradicts the rest of the assessment. The tool is a standardized measurement. Let it measure. Your judgment goes next to the score, in your own words. It doesn't replace it.

Failure three: the tool gets filled in without looking at the patient. One nurse on Reddit described a bilateral BKA patient in a wheelchair whom everyone scored as walking frequently on the Braden. Run a screening tool on autopilot and you get a falsely reassuring number. So when your assessment and the score disagree, check first whether the score was filled in right.

Failure four: the vague note. Pt seems at higher risk, precautions in place tells nobody anything. The next nurse doesn't know what to watch for. The provider doesn't know what changed.

Bottom line

Chart the score exactly as scored. Then write down what you saw that the score missed, and what you did about it.

Official guidance

  • When a suicide screen or a bedside conversation shows real risk, act on it right away: remove means, start closer observation. Chart the screening tool and the safety response you carried out. (rn-nurse.com, NurseChartingPro)
  • The Braden total puts the patient in a risk tier, and the tier sets the level of prevention. Your protocol's measures follow the number. So score it honestly, and give anything you add beyond it its own documented reason. (Philadelphia Wound Care, CASRAI)

What this rests on

No published decision turned up for this question. We looked, and the searches are in the record. So this article stands on published guidance and on how the question is asked on the floor, not on a court opinion. That is a weaker footing than the rest of the guide, and you should know it before you rely on it. The decisions behind the other articles are all in one place.

From nurses online

Quoted as written. Opinion, not a source.

Other guides

Advice, not law.