shift is wild

What you chart every shift

Describing a wound so the next nurse can actually see it

Your note is the only way the next shift sees the wound. How to chart it so they can, and why a label on its own won't do it.

8 min read built on 6 full opinions updated 2026-09-24

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

Maya reacting to this topic

You look at a sacrum, a heel or an incision once a shift. The nurse after you looks at it without you there. Your note is the only thing connecting those two looks, and if it says stage 2, dressing changed, nobody can tell whether the wound is healing, getting worse or staying the same.

The short version

  • Chart the wound you can see. Exact location. Size in centimeters (length × width × depth). The wound bed in percentages, drainage, the skin around it, pain.
  • Measure the same way every time. Length runs head to toe. Width runs side to side, at a right angle to length. Depth is taken at the deepest point. Chart tunneling and undermining by clock position, with the patient's head at 12.
  • Stage only if your facility lets you. Can't stage? Describe the wound fully and chart who you notified.
  • Compare with the last note. Bigger, smaller or the same, with the numbers. Improving by itself tells the next nurse nothing.
  • Chart skin at admission even when it's intact. A normal baseline is still a finding.

What goes wrong

The most common mistake is a label with nothing behind it: Stage 2 sacrum, foam dsg applied, pt tolerated well.

A label is a conclusion. The next nurse can't check it, can't measure against it, can't see a change from it. Say they look and the wound seems deeper. Is it worse, or did you just judge it differently? Your note won't tell them. Every note after yours repeats the same label, and a wound can look stable on paper for two weeks while it isn't.

Second mistake: the classification drifts. One shift calls it moisture damage, the next calls it a pressure injury, a third calls it a skin tear. Nobody explains the change. Anyone who later reads the chart start to finish sees three different wounds. If the classification changes, say so, say why, and say who made the call.

Third: no baseline. If the admission note doesn't say what the skin looked like, nobody can show when the wound started.

It is not hypothetical

Robinson v. Canton Harbor Healthcare Ctr., Court of Special Appeals of Maryland (now the Appellate Court of Maryland), 2024. CourtListener The appeal turned on one question. Can a registered nurse attest to what caused a pressure ulcer? Yes, said the court, if the nurse has enough training and experience. That ruling rests on a close reading of the facility's own chart. The nurse expert's report walked through the admission assessment, which said "Mr. Robinson did not have a pressure ulcer on admission". It went through the Braden score of 11 and the weekly skin notes. It also covered a sacral area where "this area was classified as Incontinence Associated Dermatitis (IAD)" before it was later tracked as a pressure ulcer. The report said that "The same sacral ulcer was initially observed as a stage 2 ulcer and had declined to a stage 3 ulcer." Every one of those entries went into rebuilding the timeline.

Canton Harbor Healthcare v. Robinson, Court of Appeals of Maryland (now the Supreme Court of Maryland), 2025. CourtListener The state's highest court affirmed the 2024 ruling in a plurality opinion. A registered nurse may attest that a breach of nursing standards caused a pressure ulcer that had already been diagnosed. The court noted that during his stay, "Mr. Robinson developed pressure ulcers, also known as decubitus ulcers or, in more common parlance, bedsores."

Magnolia Place Health Care, L.L.C. v. Jackson, Texas Court of Appeals, 9th District (Beaumont), 2021. CourtListener Among the family's claims was a failure to assess, document and report a change in the resident's condition. The receiving hospital recorded "an unstageable decubitus ulcer measuring 7x8 cm on his backside." The appeals court affirmed the trial court's refusal to dismiss the case and found the plaintiffs' expert reports sufficient. That first hospital note had a measurement. It became a fixed point in the story.

Estate of Shirley Jokinen v. Beaumont Hospital Troy, Michigan Court of Appeals, 2025. CourtListener The appeal itself was about COVID-era immunity. The court reversed the dismissal and sent the case back. But the opinion tells the facts through nursing entries. The admission exam found bruises "but no indication of pressure-related injuries such as bedsores". A skin tear on the buttocks was first noted two days later. The admission skin check set the starting point.

Mobile Infirmary Association v. Fagerstrom, Supreme Court of Alabama, 2023. CourtListener The patient's sacral injury began as a small tear and "later progressed to a Stage 3 pressure ulcer." The court reversed the jury verdict. The expert said she died of sepsis, and he based that on the usual course of such infections. The vital signs charted several times a day before her death didn't point to sepsis. What was actually charted outweighed what was assumed.

What to write instead

How it often gets charted What the next nurse needs
Stage 2 to coccyx, foam dsg applied.Coccyx, midline, 1 cm above gluteal cleft. Partial-thickness open area, 2.1 x 1.4 x 0.1 cm. Bed 100% pink-red, moist, no slough. Scant serous drainage, no odor. Periwound intact, 1 cm non-blanchable erythema at 3 o'clock. Pain 3/10 during dressing change. Foam dressing applied per order.
Wound looks better today.R heel pressure injury: 3.0 x 2.5 x 0.3 cm (on 9/17: 3.4 x 2.8 x 0.4 cm). Granulation 70% (was 50%), slough 30% (was 50%). Drainage decreased from moderate to small serosanguineous.
Red area on sacrum, pt turned.Sacrum: 4 x 3 cm area of intact skin, dark red, non-blanchable, cooler than surrounding skin, pt winces on palpation. Wound nurse consult requested; Dr. [NAME] notified at 1420. Repositioned q2h, heels offloaded.
Skin intact. (admission)Admission full skin check with [NAME], RN: sacrum, coccyx, bilateral heels, ischia, elbows, occiput intact and blanchable. Braden 12. Pressure-redistribution mattress in place.
Incision C/D/I.Midline abdominal incision 14 cm, edges approximated, 22 staples intact. No redness beyond 0.5 cm from edges, no drainage on dressing. Pt reports incisional pain 4/10.
Stage 3 healing to Stage 2.Healing stage 3 pressure injury, L ischium: 1.8 x 1.2 x 0.2 cm, 90% granulation, edges epithelializing.
IAD vs PI?Perianal/buttock skin: diffuse shiny erythema with partial-thickness denudation over 6 x 5 cm, irregular edges, no area over bony prominence. Pt incontinent of loose stool x3 this shift. Classification deferred to wound nurse, consult placed [TIME].

Words that do the damage

Word or phrase Why it hurts Use instead
looks better / healing wellNobody can check it. Nobody can measure against itToday's measurements and tissue percentages next to the last ones
small, large, quarter-sizedEveryone pictures a different sizeLength × width × depth in cm
C/D/I for a woundThat's the dressing, not the woundWound bed, drainage, periwound
red areaDoesn't say whether it blanchesblanchable or non-blanchable, plus size
bedsore, decubitusLoose terms that mix causespressure injury plus stage, or a plain description if you can't stage
Reverse staging (Stage 3 → Stage 2)Reads like a different woundhealing stage 3
WNLDoesn't say which areas you checkedList the sites you checked
tolerated wellSays nothing about the woundPain score during the dressing change
Stage with no descriptionA conclusion nobody can checkDescription first, stage after if policy allows

What the guidance says

  • Measure in centimeters and write length × width × depth the same way every time. (Relias, PatientNotes)
  • Describe the wound bed as percentages of each tissue type (granulation, slough, eschar, epithelium), not one word. (Ekagra Health, WellBX)
  • Give the location with anatomical landmarks. Say which side. (SOAP Note Buddy, ATrain Education)
  • Skip vague judgments like looks better. Chart what you actually see, and don't guess at a stage. (WCEI, WoundSource)
  • Record pain on a 0–10 scale, including during dressing changes. (SOAP Note Buddy, Lecturio)

Copy this

Initial wound assessment

`` [DATE] [TIME] Wound assessment, [WOUND #/NAME]. Location: [SIDE] [ANATOMICAL SITE], [LANDMARK, e.g. 2 cm lateral to gluteal cleft]. Type: [PRESSURE INJURY STAGE __ per policy / SURGICAL / SKIN TEAR / MASD / UNDETERMINED - WOC CONSULT REQUESTED]. Present on admission: [YES / NO / UNKNOWN]. Size: L [__] cm x W [__] cm x D [__] cm (L head-to-toe, W side-to-side). Tunneling: [NONE / __ cm at __ o'clock]. Undermining: [NONE / __ cm from __ to __ o'clock]. Wound bed: granulation [__]%, slough [__]%, eschar [__]%, epithelial [__]%. [BONE/TENDON VISIBLE: NO / YES]. Edges: [ATTACHED / ROLLED / UNDEFINED]. Drainage: [NONE / SCANT / SMALL / MODERATE / LARGE], [SEROUS / SEROSANGUINEOUS / SANGUINEOUS / PURULENT]. Odor after cleansing: [NONE / PRESENT]. Periwound: [INTACT / MACERATED / ERYTHEMA __ cm, BLANCHABLE Y/N / INDURATED / WARM]. Pain: [__]/10 at rest, [__]/10 during dressing change. Treatment: [CLEANSER], [DRESSING] applied per order. Support surface / offloading: [MATTRESS, TURNING SCHEDULE, HEEL OFFLOADING]. Braden: [SCORE]. Photo: [TAKEN PER POLICY / NOT TAKEN]. [NAME], [CREDENTIALS] ``

Reassessment with comparison

`` [DATE] [TIME] Wound reassessment, [WOUND #/NAME], [SIDE] [SITE]. Today: L [__] x W [__] x D [__] cm. Previous ([PRIOR DATE]): L [__] x W [__] x D [__] cm. Wound bed today: granulation [__]%, slough [__]%, eschar [__]%. Previous: granulation [__]%, slough [__]%, eschar [__]%. Drainage: [AMOUNT/TYPE] (previous: [AMOUNT/TYPE]). Periwound: [FINDINGS]. Pain: [__]/10 during dressing change. Change: [SMALLER / LARGER / NO CHANGE IN SIZE]; [NEW FINDING, e.g. new 1 cm tunneling at 6 o'clock / NONE]. Treatment: [DRESSING] applied per order. [NAME], [CREDENTIALS] ``

Notification of a new wound or a change

`` [DATE] [TIME] [NEW WOUND / CHANGE IN WOUND] identified during [SKIN CHECK / DRESSING CHANGE]. Findings: [SIDE] [SITE], L [__] x W [__] x D [__] cm, [WOUND BED %], [DRAINAGE], [PERIWOUND]. Compared with [PRIOR DATE]: [WHAT CHANGED, WITH NUMBERS]. Notified [PROVIDER NAME] at [TIME] by [PHONE / SECURE MESSAGE]. Response: [ORDERS RECEIVED / NO NEW ORDERS]. WOC nurse consult [PLACED / NOTIFIED] at [TIME]. Interventions in place: [SUPPORT SURFACE, REPOSITIONING SCHEDULE, OFFLOADING, MOISTURE MANAGEMENT]. Patient/family informed: [YES, NAME / NO, REASON]. [NAME], [CREDENTIALS] ``

If you remember one thing

Chart the size, the tissue and how it compares with the last note. The next nurse should be able to picture the wound without taking the dressing off.

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.

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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