Charting that holds up: a lesson in one sheet

The charting guide on this site has an article for each situation, each built on published court decisions. This page is the short version: ten rules, six entries rewritten, and questions for a class or a staff huddle. Every rule links to the articles that explain it.

Using it with a group, in 30 minutes

  1. Print it double-sided and hand it out: the rules on the front, the examples on the back.
  2. Ten minutes: go through the rules and ask for one example of each from your own unit.
  3. Ten minutes: cover the “Write” lines on the back and have people rewrite the “Instead of” entries in pairs. Then compare.
  4. Ten minutes: the questions at the bottom of the back page.

Two pages, US Letter, no ads and no sign-up. Free to print and hand out as it is, under CC BY-NC-ND 4.0.

Nursing documentation · a lesson in one sheet

Charting that holds up: ten rules

Distilled from a free charting guide where every article rests on published court decisions. Each rule names the articles that explain it.

  1. Write what you saw, not what you concluded. Findings, actions, the patient’s own words and what happened next. Labels like stable, noncompliant or drug-seeking claim more than one look can show, and a diagnosis of a patient or a coworker is not yours to chart.Read: Words to avoid · A seizure you are not sure is real · A coworker who seems impaired · A vial that looks tampered with
  2. Put a clock time on every entry, and keep two times apart. When the care happened and when you typed it are separate facts. A late entry says both. A note written after midnight never pretends it was written at 1930.Read: Late entries · Charting time vs. care time · Charting on paper during downtime · The rapid response note
  3. Say where each fact came from. A history the patient gave, a dose another nurse says she gave, an officer’s account, an AI summary: chart the source next to the fact, and mark what you could not confirm.Read: A history the records don’t show · A dose someone else says she gave · Denies vs. never asked · Acting on an AI summary
  4. Chart the response, not only the intervention. The pain score after the analgesic, the nausea after the antiemetic, what the patient could explain back after teaching. A note that stops at given or educated leaves out the result.Read: Charting the response · Pain without a number · Discharge teaching and teach-back · Doses that don’t touch the pain
  5. “Provider aware” is not a notification. Write who you told, when, what you told them, what they said and what you did next. If nobody called back, chart every attempt and how you escalated.Read: A critical lab value · No callback · Going up the chain of command · Telling the family
  6. Sign only what you checked yourself. Copied-forward findings, a WNL box, vitals the monitor sent and a note an AI drafted all become your statement once you sign. Today’s note needs today’s assessment.Read: Copied notes · What WNL leaves out · Vitals from the monitor · AI-drafted notes
  7. A blank reads as “not done.” A held dose with no number, reason and name reads like a missed dose. An assessment you could not finish needs the time, the reason and the follow-up, not an empty field or a made-up normal.Read: Holding a dose · The assessment you could not finish · The medication isn’t there · The count is off
  8. Correct openly. Mark the correction, its time and your name, and leave the original readable. Never rewrite a note after something went wrong: the audit trail keeps every version.Read: Correcting a signed note · Altering a record · Charted on the wrong patient · What the audit trail shows
  9. Keep each record in its own lane. The chart is for the patient’s care. Incident reports, staffing objections, injuries at work and HR complaints go through their own process. The chart gets what happened to the patient.Read: The incident report · An assignment you objected to · A patient hit you · A discrimination complaint
  10. Write for the stranger who reads it in two years. By then the chart is your memory. Someone who was not there should be able to rebuild the timeline from your clock times and facts without asking you.Read: Named in a lawsuit · A death on your shift · A patient who walks out · When you know you are watched

Educational, not legal advice. Your state board and your facility policy are what bind you. From the free charting guide at shiftiswild.com/notes · CC BY-NC-ND 4.0.

Instead of this, write this

Instead ofPatient fine.

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

Instead ofPt fell.

Write0215 Pt found on floor beside bed, lying on L side. Fall not witnessed. Call light within reach, bed in low position, bed alarm sounding on arrival. Pt states he was trying to get to the bathroom.

Instead ofCritical K called. MD aware.

Write1412: Received call from J. Ramos, lab tech: K+ 6.8 mmol/L, drawn 1340. Read back and confirmed. 1418: Paged Dr. A. Chen, hospitalist. 1424: Dr. Chen returned call; value and current meds (lisinopril, KCl 20 mEq daily) reported. Orders received: see below.

Instead ofDischarge instructions given. Pt verbalized understanding.

WriteReviewed 3 new meds (metoprolol, furosemide, KCl). Teach-back: pt named each med, its purpose and dose, and stated she will hold metoprolol and call if HR under 55.

Instead of1200: Lungs clear bilaterally. No respiratory complaints.

Write1200: Fine crackles at bilateral posterior bases. Respirations 20/min, unlabored. SpO₂ 95% on room air. Denies shortness of breath. 1205: Dr. Lee notified of new crackles.

Instead ofLabs pending.

Write1900: CBC ordered for 2000; specimen not yet collected. A. Patel, RN, confirmed collection and result follow-up during handoff.

Words that need something behind them

Instead ofWrite
Fine; stableRelevant findings, measurements, symptoms, and time
NoncompliantCare offered, care declined, stated reason, and response
Demanding; rude; drug-seekingSpecific requests, behavior, symptoms, and nursing actions
Will continue to monitorA specific plan plus actual reassessment entries
Provider awareName, time, information communicated, and response
UnderstandsTeach-back, demonstration, or the patient’s stated plan
Always; never; at all timesDefined times, periods, and accurately documented coverage
Tolerated wellPain, symptoms, relevant findings, and assistance needed

For discussion

  1. Pick a note you wrote this week. Which sentence says what you concluded rather than what you saw?
  2. Pain was 8/10 at 1400 and you gave the PRN at 1410. What has to be in the chart by 1500?
  3. At 0100 you realize you never charted the 1930 walk in the hall. Write the entry.
  4. The provider has not called back in twenty minutes and the patient is getting worse. What goes in the note, and in what order?
  5. A patient falls at night. What goes in the chart, what goes in the incident report, and what goes in neither?