When something goes wrong with a patient or a med

The treatment from yesterday that nobody did

Yesterday's box on the TAR is empty. What to chart now, what never to initial, and how to write it so it holds up later.

7 min read built on 2 full opinions updated 2026-10-24

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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You open the treatment administration record (TAR) and yesterday's dressing change has no initials in its box. Or the q2h turns stop at 2200. Or the bed bath box is empty. You can't tell if the care was skipped or just never charted. You still have to write something, and it has to hold up when someone reads it later.

Key points

  • Chart the blank exactly as you see it: the TAR has no entry for that date and shift. Leave the box empty. Don't initial it, and don't write not done.
  • Describe what you found at the bedside: the date on the dressing label, how the dressing looks, the skin, the position, wet or dry.
  • Chart your care at the time you actually did it, in your own entry. Never in the previous shift's slot.
  • Write down who you told, what time, and what they said back.
  • If the previous nurse did the care and forgot to sign, they can add their own late entry. You can't write it for them.

What to write

The blank itself

How people write it Better
Dressing not changed by night shift.TAR reviewed at 0715. No entry for sacral dressing change ordered q48h, last documented 10/25 at 0900.
Previous RN neglected turns.Repositioning flowsheet: last entry 10/26 2200. No entries 2200 to 0700.
(initials in the 10/26 night box)(box left empty; your own entry made at your time)
Bath missed.No bath documented on TAR for 10/26.

The condition you found

How people write it Better
Old dressing, looks bad.Sacral foam dressing labeled 10/25 with initials. Edges lifting on left side. Serosanguineous drainage saturating approx 50% of pad.
Pt left lying in urine all night.At 0720 found supine, brief saturated with urine, linen under hips wet.
Skin WNL.Sacrum: 1.2 x 0.8 cm open area, pink wound bed, no odor. Periwound skin intact, blanchable redness 2 cm around.
Wound worse.Wound measures 1.2 x 0.8 cm today. Last documented measurement 10/24: 1.0 x 0.5 cm.

The time you did the care

How people write it Better
(charting the dressing change at 0900 yesterday's time)0745 Sacral dressing changed per order: cleansed with NS, patted dry, foam dressing applied, labeled 10/27 0745 with initials.
Turned q2h. (when you just started)0730 Repositioned to left side with wedge. Heels floated.
Tolerated well.Pt grimaced during cleansing, rated pain 3/10, stated it stings. Resolved after dressing applied.

Who you told

How people write it Better
Charge aware.0750 Informed charge RN J. Patel of undocumented dressing change and wound measurement. She will notify wound care RN.
MD notified.0810 Paged Dr. Lin re wound size change from 10/24. Callback 0825, new order received: wound care consult today. Read back.
Will follow up with night shift.0755 Left message for night RN per unit process to review 10/26 TAR entries.

Template

Chart note (nursing note or wound note)

[DATE] [TIME] TAR reviewed at start of shift. No entry found for [TREATMENT, e.g. sacral dressing change ordered q48h] for [DATE/SHIFT OF BLANK]. Last documented: [DATE] [TIME].

[TIME] Assessed patient. Found [POSITION, e.g. supine, HOB 30]. [DRESSING: type, label date and initials on label, edges, drainage amount and color]. [SKIN/WOUND: location, size in cm, wound bed, odor, periwound]. [CONTINENCE: brief/linen dry or wet]. Patient reports [PAIN SCORE / WORDS].

[TIME] [CARE PERFORMED, e.g. dressing changed per order: cleansed with NS, patted dry, foam dressing applied, labeled [DATE] [TIME] [INITIALS]]. [PATIENT RESPONSE].

[TIME] Informed [NAME, ROLE] of undocumented [TREATMENT] for [DATE/SHIFT] and current findings. Response: [WHAT THEY SAID OR ORDERED].
[TIME] [PROVIDER NAME] notified re [FINDING]. Orders received: [ORDERS / NONE]. Read back.

Message to charge nurse or manager

[NAME], at [TIME] on [DATE] I found no TAR entry for [TREATMENT] for patient in [ROOM] for [DATE/SHIFT]. Last documented entry was [DATE] [TIME]. On assessment the [DRESSING/SKIN/POSITION] was [BRIEF FACTS]. I completed [CARE] at [TIME] and documented it. [PROVIDER NAME] notified at [TIME]: [RESPONSE / NOT REQUIRED PER ORDER]. Please advise if the [SHIFT] nurse should review the entry or if an event report is needed per policy.
[YOUR NAME], [CREDENTIALS], [UNIT], [PHONE/EXT]

Event or incident report (if your facility's policy calls for one)

Date/time discovered: [DATE] [TIME]
Location: [UNIT], [ROOM]
What was found: TAR has no entry for [TREATMENT] ordered [FREQUENCY] for [DATE/SHIFT]. Last documented [DATE] [TIME].
Patient condition at discovery: [DRESSING LABEL DATE, DRAINAGE, SKIN/WOUND SIZE, POSITION, CONTINENCE].
Actions taken: [CARE PERFORMED] at [TIME]. [NAME, ROLE] informed at [TIME]. [PROVIDER] notified at [TIME], orders: [ORDERS].
Patient outcome at time of report: [CURRENT STATUS].
Reported by: [YOUR NAME], [CREDENTIALS]

Many facilities ask you not to mention the event report in the patient's chart. Check your policy.

Words to avoid

Word or phrase Why it hurts Use instead
not doneYou don't know that. You know it isn't charted.no entry on TAR for [date/shift]
neglected, failed to, missedBlames a person. And you can't back it up.The date and time of the last documented entry
night shift didn'tSame thing, aimed at a whole shift.last documented [time]
appears to have been leftA guess dressed up as an observation.What you saw: the label date, saturation, position
old dressingOld tells the next reader nothing.dressing labeled [date] [time]
WNL, skin intact (copied forward)Pulled from an earlier note. Today may look different.Today's measurements and description
tolerated wellSays nothing about what happened.What the patient did and said
will continue to monitorCharts something that hasn't happened yet.The actual next check, charted when you do it

Filling the gap with a guess

The most common mistake is filling the gap. You find a blank box, figure the care probably happened, and initial it. Or you figure it didn't happen and write dressing not changed by night shift. Both put a guess in the chart under your name.

Initial a box you didn't do and you've charted care you didn't give. Write not changed by night shift and you're making a claim about a shift you never saw. All you know is that the record is empty. Maybe the dressing got changed and nobody signed. Maybe it didn't. The label, the drainage and the skin are your evidence. Put them in the chart in plain words.

The second mistake is quieter. You find the gap and start fresh, as if the wound or the problem began on your shift. You copy yesterday's description forward, or open a new record with no link to the old one. Now the timeline is broken. And a break in the record looks like a break in care, even when nothing was missed.

Bottom line

Chart the empty box as empty. Chart the patient as you found them. Chart your own care at your own time.

Official guidance

  • Chart care after you've done it, as close to that time as you can. Never ahead of the care. (simplenursing.com, asrn.org)
  • Don't carry the old wound, skin or assessment description forward. Look at the patient and write what's there now. Copied text hides changes. (textexpander.com, nursemagic.ai)

In court, 2008–2016

What happened in 2 court cases

Farrell v. Regent Care Center of the Woodlands: Texas Court of Appeals, 9th District (Beaumont), 2016. A nursing home resident had a stage two sacral pressure ulcer and an order for a dressing change every other day. At trial the family's expert argued the order went unfollowed for about twelve days, because "Regent Care’s medical records contain no documentation showing that the dressing on the wound was changed during that time period." The treatment nurse testified that two wounds had merged. She started new treatment records for the merged wound and sent the older pages to medical records. What happened to them after that, she didn't know. The new records called the wound new, with an onset date of May 11. The facility answered with the charge nurses' daily notes. The jury found for the facility, and the appeal (about excluded billing records) was affirmed. Still, the whole trial fight was about a stretch of the TAR with nothing in it.

Maxwell v. Baptist Memorial Hospital-DeSoto: Court of Appeals of Mississippi, 2008. A patient developed a stage IV pressure ulcer in the hospital. The family's nurse expert wrote in her affidavit that "often the records were void of entries indicating that a treatment was done to the wound." That's what the expert alleged. The court made no finding on it. The trial court struck the affidavits as filed too late, and the appeals court affirmed summary judgment for the hospital. What the case does show: the first thing a reviewer hunts for in the chart is empty treatment entries.

Court decisions

Published decisions, linked to CourtListener.

All decisions behind this guide

From nurses online

Quoted as written. Opinion, not a source.

  • If you find tasks not done from a previous shift, you chart in Epic factually but briefly, ie “tube feed disconnected and stoma care completed, etc,” and then you file an incident report that goes to your director as well as your manager.

    r/nursing on Reddit: Putting too much in the nursing notes reddit

  • If for some reason it has to be completed while on your shift, I’d note it was hung prior to your receiving report and was not documented. ... You should not document tasks done by the previous nurse. Objective observations, sure, but not that they hung the medication (someone else may have hung it

    r/nursing on Reddit: Should you chart tasks done by the previous nurse? reddit

  • I went back to look at the dressing charting and everyone charted “ddi” (this hospital also seems to be the CEO of using whatever acronyms they want). After considering all options, I assumed everyone was just charting “dressing dry, intact” but I truly decided what they meant was “didn’t do it” 🤷🏼‍

    r/nursing on Reddit: Is it not standard to chart by exception? reddit

  • In my hospital, if the tech doesn't do something, the nurse is in trouble for not making sure the tech did everything 🙃 ... I chart gown changes in step-down but can't be assed on the ward. ... All I can think of is CYA. I don’t think there’s even a place in our charting to dress “gown cha

    r/nursing on Reddit: Forgot to Chart Life-Saving Gown Change reddit

Other guides

Advice, not law.