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What to write when it goes wrong
241 lines you can copy into a note, taken from the charting guide on this site. Each one comes from an article built on published court decisions, and the link under every block opens the reasoning behind it.
These are written examples, not excerpts from anyone's chart. Put your own facts in: your times, your findings, your words. A line that is not true for your patient is worse than no line at all.
Any note: how it gets read
When you acted on the AI summary instead of the chart
- Allergy list in chart opened 0712: penicillin (rash, entered 9/26). Cefazolin held. Dr. [NAME] notified 0715.
- AI chart summary listed K 4.1. Results tab checked 0930: most recent K 3.2, collected 0505. Previous 4.1 was from 9/25. KCl given per protocol after confirming current value.
- Code status verified in active orders 1905: DNR/DNI, order dated 9/27 by Dr. [NAME]. AI summary displayed Full Code; reported discrepancy to charge RN [NAME] 1910.
Signing an AI-drafted nursing note
- 0735 Pt awake in bed, grimacing with movement. Reports abdominal pain 7/10. Abdomen soft, tender to RLQ on palpation. PRN pain medication given per MAR at 0742. Reassessed at 0815, pain 4/10, pt states pain is tolerable.
- 1010 Pt requested bathroom assistance. Ambulated 12 ft to bathroom with gait belt and assist x1. Unsteady when turning. Non-skid socks on, bed alarm reactivated after return to bed, call light within reach. Reinforced use of call light before getting up.
- 1130 Right lower leg dressing with small amount of serosanguineous drainage at distal edge. Dressing reinforced per wound order. Surrounding skin warm, no odor noted. Photo uploaded per policy. Provider notified at 1145 by secure message; no new orders at this time.
When the patient does not want the room listened to
- 0815 Explained ambient documentation tool to pt: device listens to room audio, drafts note for RN review, pt may decline or stop at any time. Pt agreed. Device on 0817.
- 0815 Offered ambient documentation tool, explained purpose. Pt declined, stated does not want conversations recorded. Device not activated. Note entered manually by RN.
- 1040 Pt asked that the listening device be turned off. Device stopped 1041. Entries before 1040 drafted by ambient tool and reviewed by RN; entries after 1041 written by RN without device.
The assessment you could not finish
- 0745 Pt transported to IR for PICC placement via stretcher with transport, on 2L NC, SpO2 96% at departure. 0800 scheduled assessment deferred, pt off unit. 0935 pt returned to unit. Full assessment completed 0945, see flowsheet.
- 0800 pt in CT, off unit since 0750. Assessment not performed at scheduled time. Assessed on return 0840: A&O x4, lungs clear bilat, abd soft, non-tender. Contrast site L AC without swelling.
- 0400 pt asleep, first sleep since 0130 per pt report of pain overnight. Observed from bedside without waking: RR 16, even and unlabored, skin color pink, SpO2 95% on RA per monitor, HR 78 SR on tele. Full assessment deferred to allow rest, no acute findings. Will reassess at 0600 with vitals.
Charting that a doctor did not respond, without blame
- 1405: Scheduled 1400 cefazolin not available in dispensing cabinet. Spoke with J. Lee, PharmD; Lee reported dose being prepared and estimated delivery at 1420. 1410: Updated Dr. Patel on medication delay. 1425: Dose received and administered; see MAR.
- 0930: A. Gomez, RRT, reported nebulizer treatment completed at 0920. 0932: On my assessment, RR 20/min, SpO₂ 95% on 2 L/min nasal cannula; patient speaking in full sentences.
- 0800: Spoke with K. Davis, staffing coordinator, regarding ordered continuous observation. Davis reported assignment pending. 0805: Charge RN notified; I remained at bedside pending coverage. 0820: L. Brown, patient observer, arrived at bedside. Handoff completed; Brown assumed continuous observation.
Exceptions to WDL in Nursing: Meaning and How to Chart
- 0800: BP 128/74 mm Hg, HR 78/min, RR 16/min, temperature 36.8°C oral, SpO₂ 97% on room air.
- 0800: Alert; oriented to person, place, date, and situation. Left grip weaker than right, unchanged from documented admission assessment. Speech clear; no facial droop.
- 1400: Lower abdominal dressing intact with 3 × 2 cm area of serosanguineous drainage, unchanged from 1200. Incision not visualized beneath dressing.
Copy-paste charting: why cloned notes stop counting
- 1200: 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.
- 1200: Alert; oriented to person, place, time, and situation. Speech clear. Hand grips and bilateral ankle dorsiflexion equal. These findings are unchanged from my 0800 assessment.
- 1500: Reports incisional pain 6/10 at rest. Ordered PRN analgesic administered; see MAR. 1545: Reports pain 2/10 at rest.
Denies versus never asked in the admission history
- Allergies: Pt states no known drug, food, latex or environmental allergies. Asked each category separately. Pt A&Ox4, answered without hesitation.
- Seizure hx: Pt unable to answer reliably (oriented to self only). Wife [NAME] by phone states no seizures she is aware of; married 30 yrs. Prior records not yet available. Will review when received.
- Falls in last 6 months: Pt states none. Daughter at bedside states pt fell at home approx. 2 wks ago, no injury reported, did not seek care. Fall risk scored using daughter's report.
Validating the vitals the monitor sent to the chart
- 1320 SpO2 81% auto-filed, rejected: pt alert, talking in full sentences, color pink, pleth waveform flat/irregular, finger cold. Probe moved to earlobe. 1324 SpO2 95% RA, good waveform. RR 16.
- 0615 HR 158 auto-filed, rejected: pt brushing teeth at sink, leads II/V1 showing motion artifact on strip. Apical HR 1 min at 0619 = 84, regular. Pt denies palpitations, dizziness.
- 1330 NIBP 68/40 auto-filed, not accepted: cuff over antecubital with arm flexed. Pt alert, oriented x4, skin warm/dry, denies lightheadedness. 1334 manual BP L arm, supine, adult cuff = 118/72, HR 78.
When the flowsheet and your note do not match
- 1410: Stage 2 pressure injury to sacrum, 2 x 1.5 cm, pink wound bed, no drainage. Not present on 0800 assessment per my exam at that time. Flowsheet skin row updated at 1410. Wound care consult ordered per protocol, Dr. [Name] notified 1420. Pt repositioned q2h, sacral foam dressing applied.
- 0915: MAR shows metoprolol 25 mg PO documented as given at 0900. Medication was not given. Apical HR 52 at 0855, BP 98/60. Dose held per parameters. MAR entry corrected at 0915 to show not given, reason documented. Dr. [Name] notified 0920, no new orders.
- 1300: Pain 8/10 L hip per flowsheet. Pt grimacing, guarding with turns. Oxycodone 5 mg PO given 1305 per MAR. Reassessed 1405: pain 3/10, pt sleeping between checks, easily woken.
Charting pain when the patient cannot give you a number
- 1410 FLACC 7 (F2 grimace/quivering chin, L2 kicking, A1 squirming, C1 intermittent crying, C1 consoled by parent's touch). Surgical site dressing dry. Morphine 0.05 mg/kg IV = 1 mg given 1415 per order.
- 1445 FLACC 1 (F1 occasional frown, L0, A0, C0, C0). Asleep on mother's lap, face relaxed, legs still. RR 22.
- Crying started after parents left the room at 1600; stops when held; face relaxed, legs relaxed. FLACC 2. Distress appears separation-related; no analgesic given; will reassess in 30 min.
When the patient reports a history the records do not show
- Pt's daughter (at bedside) reports pt had a seizure in approx. spring of this year; states, in her words, [DAUGHTER'S WORDS]. No seizure hx, neuro consult or antiepileptic found in records available in this EHR. Dr. [NAME] notified 2140. Seizure precautions initiated per order.
- Pt reports sulfa allergy; describes reaction as itchy rash on arms after taking an antibiotic approx. 10 yrs ago, name of drug unknown. Not listed in prior allergy record. Entered in allergy field as patient-reported, reaction: rash. Pharmacy notified.
- Pt reports being told of epilepsy dx at another hospital in [YEAR]; states stopped [MED NAME, if given] approx. [TIMEFRAME] ago. No epilepsy dx or antiepileptic on current outside med list. Records release signed; request faxed to [FACILITY] 1015.
Describing a seizure you are not sure is real
- 0212 Pt found in bed with bilateral arm and leg shaking, side-to-side head movement. Eyes closed. Event timed 0212–0216 (4 min). SpO2 97% RA during event.
- During event, called pt's name x3, no verbal response. Touched shoulder, no response. Shaking stopped at 0216; pt answered questions at 0217, oriented x4.
- Shaking began after pt was told discharge is delayed (per pt's mother, at bedside). Movements decreased when staff left room, increased when staff re-entered x2. Provider notified of event and observations at 0225.
Words to never chart in a nursing note
- 0100: Awake; answers questions appropriately. Respirations 16/min and unlabored. Denies shortness of breath.
- 1400: Peripheral IV site without visible redness or swelling; patient denies site pain. Separate later entry: 1500 IV site reassessed; no redness, swelling, or leakage observed. Patient denies site pain.
- 0830: Declined shower, reporting fatigue. Offered seated wash at bedside. Accepted assistance washing face and upper body; declined remaining hygiene care at this time. Plan to reoffer after rest.
Everyday charting
The skin check at the start of your shift
- 0715 full skin check, pt turned side to side with off-going RN J. Lopez present. Scalp, face, ears, neck, chest, abdomen, back, sacrum, buttocks, perineum, bilat arms/hands, bilat legs/feet inspected. No bruising, redness, swelling, or open areas found. Under ID band, SpO2 probe site, and ETT tape inspected: no marks.
- L forearm, dorsal, 4 cm below elbow crease: purple-blue bruise 3 x 2 cm, oval, skin not broken, no swelling, no grimace on palpation. Present at start of shift, 0720. Noted in handoff by off-going RN.
- Bilat forearms: 7 bruises, 1–4 cm, purple to yellow-green, none open. R lower leg: 2 bruises, 2 cm and 3 cm, purple, none open. Pt on apixaban per MAR. All present at start of shift, 0730. Photo per unit policy: [yes/no].
Documenting critical lab value notification
- 1412: 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.
- 0215: Plt 22 K/uL (prior 48 K/uL on 9/22) reported by phone to Dr. M. Patel, night hospitalist, with trend and scheduled 0600 heparin. Read back by Dr. Patel. Orders: hold heparin, repeat CBC 0600. Heparin held; charge RN S. Lee informed.
- 0305: Glucose 42 mg/dL (POC, confirmed with lab draw). Hypoglycemia protocol started, D50 25 mL IV given 0308. 0310: Secure chat sent to Dr. R. Okafor, on-call per schedule. 0325: No response. Paged Dr. Okafor. 0331: Dr. Okafor returned call; value, treatment, and 0323 recheck 88 mg/dL reported. Orders received.
When a patient dies on your shift
- 0005 Rounded on pt. Observed from bedside with penlight. Pt lying on L side, eyes closed, chest rise visible, RR 16 regular, no snoring or gurgling. Skin color pink. Did not wake pt. Call light in reach, bed low, rails x2.
- 0310 Entered room for scheduled VS. Pt supine, eyes open, no chest rise observed. No response to verbal or sternal rub. No carotid pulse palpated. Skin pale, cool to touch on hands. Called for help, pressed code button 0311. Began compressions 0311.
- 0312 Rapid response/code team paged via code button. 0314 Dr. [Name], hospitalist, at bedside, assumed code lead.
Documenting discharge teaching and teach-back
- Reviewed 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.
- Return demonstration: pt removed old dressing, cleaned incision with saline, applied dry gauze without prompting. Correctly named redness, drainage, fever over 100.4 F as reasons to call surgeon.
- Pt stated she will call Dr. [NAME]'s office for appointment within 7 days. Pt wrote clinic phone number in her phone in front of RN.
Documenting a held medication dose
- 0745 Glargine 20 units not given. FSBG 64 mg/dL at 0730, pt diaphoretic, alert. Hypoglycemia protocol started, 4 oz juice given. Dr. Patel paged 0740, called back 0748: hold AM glargine, recheck BG in 15 min. BG 0805: 102 mg/dL.
- 1130 Lispro sliding scale not given. FSBG 142 mg/dL. Pt NPO since midnight for EGD at 1300. Order has no NPO hold parameter; called Dr. Kim 1125, order received to hold correction dose while NPO, resume with first meal tray. Next BG due 1530.
- 0215 Heparin infusion paused per heparin nomogram. aPTT 128 sec (resulted 0200). Rate before pause 1,200 units/hr. Paused 0215 x 1 hr per nomogram, restart 0315 at 1,050 units/hr. Next aPTT due 0915. No bleeding noted at IV site, gums, urine. Charge RN Lopez notified.
The controlled drip you took over at handoff
- 1915 Midazolam infusion received at handoff. Bag label: midazolam 100 mg/100 mL (1 mg/mL). Volume remaining by visual check approx. 40 mL. Pump: 2 mL/hr = 2 mg/hr. Checked with A. Patel, RN. Label and pump concentration match. No titration at time of handoff.
- Separate entry: 1945 Fentanyl increased from 50 mcg/hr (5 mL/hr) to 75 mcg/hr (7.5 mL/hr) per titration order for CPOT 5. Reassess at 2015.
- 1920 Bag at handoff contained approx. 8 mL. New bag hung 1920: fentanyl 1,000 mcg/100 mL, label checked with J. Ortiz, RN. Old bag with remaining approx. 6 mL wasted with J. Ortiz, RN per unit waste process; waste documented in [DISPENSING SYSTEM].
Documenting interpreter use
- Pt offered professional Vietnamese interpreter at no cost; pt declined, stated via son that she prefers her son, [NAME], interpret. Son [NAME], age 34, interpreted for pain reassessment.
- Discharge teaching (metoprolol, daily weights, when to call MD) done via phone interpreter, Arabic, ID #[ID]. Pt repeated back through interpreter: take 1 tab twice a day, weigh every morning, call for gain of 3 lb in 2 days.
- Phone interpreter line unavailable at 0310 (hold >15 min). Non-urgent teaching deferred. Urgent info (call light use, NPO status) given with pictogram card; pt demonstrated call light use. Interpreter reattempted at 0600, reached, NPO status reviewed with interpreter ID #[ID].
Documenting IV infiltration and extravasation
- 0600 L forearm 22g PIV: no swelling, no redness, no leaking, skin warm and soft, compared to R arm. Dressing intact. Flushes without resistance. TPN at 4 mL/hr and lipids at 0.5 mL/hr via pump, pressure within range.
- 0930 Phenytoin 1 g IV in NS 100 mL given via L IJ CVC, distal lumen. Blood return confirmed before start. L hand and L wrist PIVs not used. Site checked at 15 min: no swelling.
- 0200 L forearm former PIV site: swelling now approx 2 x 3 cm (was 4 x 5 cm at 2200), soft, skin pink, no blistering. Cap refill <3 sec, moves all fingers, sensation intact. Pt reports pain 1/10. Photo taken with unit camera per policy and uploaded to chart.
Documenting lines, drains and tubes
- L forearm 20g PIV, inserted 6/12. Site without redness, swelling or tenderness. Dressing dated 6/12, dry and occlusive. Flushes without resistance, blood return present. NS infusing at 75 mL/hr.
- R IJ triple-lumen CVC. Dressing dated 6/10, dry and occlusive, no drainage. Neck soft, no swelling or bruising at site. All lumens flushed, blood return x3. Distal: norepinephrine per MAR. Medial and proximal: saline-locked.
- 16 Fr indwelling catheter, placed 6/11. Draining clear yellow urine, 45 mL/hr average over past 4 hr. Tubing without kinks, bag below bladder, securement device on R thigh. Perineal care done.
Documenting patient belongings and valuables
- Belongings bag x1 (blue jeans, gray sweatshirt, black sneakers, black backpack) sent with pt to 4 West at 1420. Received by J. Lee RN.
- Brown leather wallet containing cash counted with pt: $62 (three $20 bills, two $1 bills)
- Yellow metal band with clear stone, L ring finger, removed pre-op. Given to pt's husband, R. Diaz, at 0715. Husband signed belongings form. Pt awake and agreed.
Documenting a patient fall: the post-fall note
- 0215 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.
- Head-to-toe: no lacerations, bruising, or swelling noted. Legs equal length, no external rotation. Moves all extremities, full ROM without pain. Pt denies hitting head. Pain 0/10.
- BP 148/86, HR 92, RR 18, SpO2 96% RA, T 36.8 C, BG 132.
Documenting a change in condition and rapid response
- 1412 Pt states I can't catch my breath. RR 30, SpO2 88% on 2L NC (was 95% at 1200), HR 118, BP 102/64, T 38.4. Lung sounds diminished R base. HOB raised to 45°. O2 increased to 4L NC per protocol.
- 1418 Paged Dr. [Name], hospitalist. Reported via SBAR: new SOB since ~1400, RR 30, SpO2 88% on 2L, HR 118, T 38.4, diminished R base. Requested bedside eval. Dr. [Name] stated will come to see pt within 15 min; ordered CXR, CBC, lactate, blood cultures x2.
- 1440 Pt opens eyes to voice only, oriented to self only (was A&Ox3 at 1200). RR 34, SpO2 86% on 4L, BP 88/50, HR 124. Dr. [Name] not yet at bedside. RRT activated 1442.
Restraint documentation for nurses
- 0215 Pt pulled at R IJ central line dressing x3 and struck at RN with R hand. Reoriented, sitter requested (unavailable), mitts offered and removed by pt. Soft bilateral wrist restraints applied 0225. Dr. Patel notified 0227, order received 0230 for non-violent soft wrist restraints.
- 0245 Soft wrist restraints intact, 2 fingers fit under each. Hands warm, pink, cap refill <3 sec bilaterally, no skin redness. Pt picking at sheets, reaching toward line when spoken to. Offered water, took 60 mL.
- 0415 Pt asleep, arousable to voice, oriented to name only. Released one limb at a time for ROM, no resistance. Skin intact at wrists. Offered urinal, voided 250 mL. Restraints reapplied, pt no longer reaching for line when awake. Will reassess for release at next check.
Wound and pressure injury documentation
- 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.
- 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.
- 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.
Timing: late, during a code, on paper
Altering a medical record: what spoliation means
- Identify both the entry time and event time:<br><br>09/13/2026 0730: Late entry for 09/12/2026 at 1400: Patient found seated on floor beside bed. Patient reported right hip pain rated 6/10. Charge nurse and Dr. Lee notified at 1405 on 09/12/2026.
- Make the changed fact explicit:<br><br>09/13/2026 0815: Correction to nursing note dated 09/12/2026 at 1030: Dr. Lee was notified at 1025, not 1005 as previously entered.
- Correct the unsupported statements without inventing replacement care:<br><br>09/13/2026 0900: Correction to nursing note dated 09/12/2026 at 0900: Repositioning and intact sacral skin were documented in error. I did not reposition the patient or assess the sacral area at that time.
When the billable visit did not happen
- 05/12/2026 0915 Scheduled skilled nursing visit not provided. Arrived at home at 0905; no answer at door. Called patient at 0908 and caregiver at 0910; no answer. No assessment or skilled nursing care provided. Scheduler and RN supervisor J. Smith notified at 0915. Visit status updated as missed visit.
- 05/12/2026 Behavioral health skills group scheduled 1000-1100. Client arrived at 1025 and left at 1050 for transportation. Actual group time 25 minutes. Client participated in grounding exercise and check-out. No safety concerns stated during time present. Note reflects actual time present only.
- 05/12/2026 1400 scheduled repositioning not completed at scheduled time. Patient required two-person assist; second staff member not available 1355-1425 due unit acuity. Charge RN M. Lee notified at 1405. Patient repositioned to left side with pillows at 1430 with CNA assist. Sacrum intact, no redness noted at 1430.
Charting during a code when roles overlap
- Late entry at 1038 for Code Blue in Room 412. This RN arrived at 0953 and served as medication nurse from 0955 to 1008. Events before 0953 were not personally observed by this RN.
- Epinephrine 1 mg IV push given via right AC PIV at 0956 per Dr. Patel verbal order during code. Flushed with 20 mL NS. Medication and time announced to code recorder. Additional epinephrine doses documented in MAR at 1000 and 1004.
- At 0952, patient found unresponsive with no pulse palpated by this RN. Code Blue activated. Chest compressions started by this RN at 0952 and continued until relieved by J. Lee RN at 0955. This RN resumed compressions from 1002 to 1004.
Charting on paper when the system goes down
- Administration time set to 09:10. Comment: Downtime entry transcribed from paper downtime MAR. Given 09:10 by [initials].
- Assessment filed at 08:30, with each system actually documented. Comment: Entered after EHR downtime 07:45–14:20 from paper downtime flowsheet.
- Downtime 07:45–14:20. All vitals, I&O and meds from paper downtime forms entered at original times. Paper forms sent for scanning per policy.
Charting a group session one patient at a time
- Coping skills group 1000–1045. Pt present 1000–1045. Volunteered once, named walking after dinner as a coping strategy he uses. Completed 4-7-8 breathing exercise with group, stated afterward he felt less tense.
- Med education group (antipsychotics, side effects) 1400–1440. Pt arrived 1418, missed first half of content. Left at 1432 stating she needed the bathroom; did not return. Handout given to pt at 1450; RN reviewed side effect section with her 1:1, pt able to name dry mouth and drowsiness.
- Relapse prevention group 1300–1350. Pt present full session. Silent first 20 min, arms crossed. Spoke once near end, stated: I don't have triggers, I just drink when I'm bored. First verbal contribution in group this admission (previous 3 groups: no verbal participation per notes).
Late entry charting: adding a note after your shift
- Show both dates and times:<br><br>09/12/2026 0015: Late entry for care provided 09/11/2026 at 1930: Assisted patient to ambulate 50 feet with walker. Patient denied dizziness during ambulation. J. Lee, RN.
- Identify the original note and the communication:<br><br>09/12/2026 0900: Addendum to nursing note entered 09/11/2026 at 1810: At 1805 on 09/11/2026, notified A. Patel, NP, by telephone of temperature 38.2°C and heart rate 108/min. No new orders received during that call. J. Lee, RN.
- State the timing you actually know:<br><br>09/12/2026 0910: Late entry for care provided during the 1500–2300 shift on 09/11/2026: Reinforced right forearm dressing with gauze. Exact time not recalled. J. Lee, RN.
Charting in real time vs at end of shift
- Entered at 1015, displayed only under 0730: Alert and oriented ×4. Respirations unlabored. Denies shortness of breath.
- 1800: Patient nauseated earlier. MD aware. Medication effective.
- 09/09/2026, 0015: Abdominal dressing dry and intact.
When something goes wrong with a patient or a med
How to document controlled substance waste
- 2310 Morphine sulfate 2 mg IV given via L forearm PIV for pain 8/10. Medication removed as 4 mg/1 mL vial. 2 mg administered; 2 mg wasted immediately in approved controlled-substance waste container with J. Smith, RN witness in Omnicell. Pain reassessed 2340, 4/10.
- 0145 Hydromorphone 0.5 mg IV slow push given via R hand PIV per order. Vial contained 1 mg/1 mL. Remaining 0.5 mg wasted at time of administration with M. Lopez, RN witness; waste documented in Pyxis. RR 16, patient awake and reports pain decreased from 9/10 to 5/10 at 0215.
- 1022 Fentanyl 25 mcg IV administered for dressing change per order. 50 mcg/1 mL vial removed. 25 mcg administered; 25 mcg wasted in approved controlled-substance waste container with K. Patel, RN witness and ADC waste entry completed.
When you gave the dose but the MAR missed it
- Late eMAR entry completed at 1038. Oxycodone 5 mg PO administered at 1012 for pain 8/10 per active PRN order. Bedside scan did not transmit after two attempts due to scanner error on WOW-3. Patient identified with name and DOB; medication verified against active MAR before administration.
- Morphine 2 mg IV push administered at 1416 through left forearm PIV for pain 9/10. Unit-dose barcode unreadable; manual verification completed against active order and allergy list before administration. Charge RN A. Smith notified at 1425.
- Hydromorphone 1 mg/1 mL removed from ADC at 0754. Administered 0.4 mg IV push at 0801 per order. Wasted 0.6 mg in medication room with J. Lee, RN, witness, at 0804. ADC discrepancy reviewed and resolved with witness.
When the new EHR is missing old information
- Pre-go-live MAR history not visible in new EHR as of 0715. Last dose of metoprolol 25 mg PO per transfer MAR from 4 West: 2100 on 10/05. Confirmed with pharmacist J. Ruiz at 0730 by phone. Next dose given 0900 as scheduled.
- Allergy field empty after migration. Allergies verified verbally with patient: penicillin (hives), sulfa (rash). Entered manually 0745. Pharmacy notified 0750 for profile review.
- Active orders not displaying since 1400 (interface issue per help desk ticket #48213). Dr. Patel called 1415, current orders read back and confirmed, written on downtime order sheet and placed in chart. Charge RN M. Lee aware.
When the family finds an injury you did not chart
- 1540: Patient's daughter pointed out discoloration on L upper arm. On assessment: purple-blue area, 4 cm x 3 cm, lateral L upper arm, 5 cm above elbow. No open skin. Mild tenderness on palpation per patient, 2/10. Last documented skin assessment 0800 today, L upper arm recorded as intact, no discoloration.
- R lateral hip: yellow-green discoloration, 6 cm x 5 cm, irregular border, no swelling, no open area. Patient states she does not recall how it happened. Admission skin assessment [date] 1900 does not document a finding at this site.
- Son at bedside asked about swelling to R wrist. Findings reviewed with son. Charge RN J. Park notified at 1615 and came to bedside at 1625.
When the medication is not there to give
- Not given. Metoprolol 25 mg not in ADC or patient bin at 0900. Pharmacy called 0905, spoke w/ J. Lee RPh, dose being sent from main pharmacy, ETA 30 min.
- Not given at 0800. Vancomycin 1 g IV not delivered; not in unit fridge. Pharmacy called 0810, bag in compounding, ETA 0930. Dr. Patel paged 0815 re: delay, OK to give on arrival. Will chart actual time.
- Levetiracetam 500 mg not available 3rd consecutive dose per MAR. No DC order found in chart/eMAR. Pharmacy closed overnight; on-call pharmacist paged 2210, no callback by 2240. On-call provider Dr. Kim paged 2245, advised [instruction]. Charge RN M. Ortiz notified.
The narcotic count is off at shift change
- Count done together at 1905 by [both names]. Oxycodone 5 mg card #A: sheet 12, actual 11. DISCREPANCY. Charge RN notified 1910.
- Single line through 12, written 11, initials, date, time. See variance report #__.
- Morphine 20 mg/mL oral solution: expected 15 mL, measured 34 mL. Overage. Not used, set aside, charge RN and pharmacy notified [time].
When the charted doses are not touching the pain
- 1410 hydromorphone 1 mg IV given per MAR. 1440 reassess: pain 8/10 abd, unchanged from 1400. Guarding, HR 108, unable to reposition without assist.
- 1830 pt reports pain 9/10 incision, sharp, constant. Per MAR, oxycodone 10 mg PO last documented 1630. Pt states pain has not dropped below 8 since this morning. VS: HR 112, BP 158/92, RR 20.
- Pain scores after last 4 doses per MAR (0600, 1000, 1400, 1800): 8, 9, 8, 9. Current PRN regimen not controlling pain. Dr. [NAME] paged 1845.
When the patient walks out before discharge
- 0200 Pt observed in bed during hourly rounding, eyes closed, resp even and unlabored. 0310 Pt not in room, not in bathroom or hallway. Personal belongings and coat gone. Charge RN [NAME] notified 0312; unit and lobby search per policy 0312–0325, pt not found. Security notified 0315.
- Pt requested PIV removal before leaving. 20g PIV R forearm removed 2040, catheter tip intact, site without redness or swelling, pressure held 2 min, dressing applied.
- Pt declined PIV removal and left the unit 2045 with 20g PIV L hand in place. Explained risks of infection, bleeding, and air entering the vein; advised to return or go to nearest ER for removal. Dr. [NAME], charge RN [NAME], and security notified 2047. Emergency contact [NAME] called 2050, informed PIV in place.
Giving a PRN sedative for behavior
- 1830 Resident moaning, grimacing, guarding L hip, PAINAD 7. Repositioned, warm blanket, no change at 15 min. Morphine 5 mg PO given per PRN order for pain. 1915 PAINAD 2, sleeping, arousable to voice, RR 14, SpO2 94% RA.
- Redirection attempted x 2 (offered walk, offered TV in room); resident pushed staff away both times and continued shouting at roommate. Roommate moved to dayroom for safety.
- 1 hr post-dose: seated in chair, conversing with staff, no further exit attempts. Sedation: drowsy, easily aroused (POSS 2). No falls.
You pulled the medication but never gave it
- MAR: 0912 Oxycodone 5 mg PO not administered. Order discontinued by J. Lee, MD, at 0910, before administration.<br><br>Return record: 0918 Oxycodone 5 mg, 1 unopened unit-dose tablet returned to the ADC designated return bin using the return transaction linked to the 0905 removal.
- MAR: 1110 Oxycodone 5 mg PO not administered. Patient declined dose when offered.<br><br>Waste record: 1114 Oxycodone 5 mg, 1 opened unit-dose tablet wasted in the approved controlled-substance waste system; linked to the 1105 removal. Waste observed and electronically verified by M. Jones, RN.
Assignment Despite Objection: what to file and what to chart
- Patient chart: 1400 Scheduled two-person repositioning delayed; second staff member unavailable. Charge RN notified at 1402 and assistance requested. At 1415, repositioned patient onto left side with RN assistance; heels offloaded. Sacral skin intact without erythema.
- Patient chart: 0710 Brief and gown wet with urine on initial assessment. Perineal skin erythematous and intact. Incontinence care provided; skin barrier applied per care plan. Dry brief and gown placed. Patient repositioned.
Charting suicide precautions that show actual observation
- 0715 Pt visually observed in room 412, sitting on bed facing doorway. Awake, tearful, rubbing hands together. Hands and neck visible. No self-harm gestures observed. Trash can empty; meal tray removed; bathroom door open; no cords or loose items visible from doorway. q15 precautions continued.
- 0230 Pt observed in bed, left side, eyes closed. Chest rise visible; respirations even and unlabored. Room light on per suicide precautions. Bedding on bed only; no extra linens observed. Bathroom door open. q15 precautions continued.
- 1430 Continuous 1:1 observation maintained by MHT Davis, seated inside doorway with unobstructed view of patient. Pt in recliner watching TV, hands visible, calm, responds to name. No self-harm gestures observed. Environment scan completed: tray removed, trash empty, belongings secured per precautions.
When a syringe or vial looks tampered with
- “1402 Cefazolin IVPB bag delivered for patient with active order for ceftriaxone 1 g IV q24h. Bag label medication name did not match MAR order. Bag not spiked and medication not administered. Pharmacy notified at 1405. Dose held pending replacement from pharmacy. Provider notified of delay at 1410.”
- “1120 Heparin vial inspected after cap removal and before administration. Black rubber-appearing particle approximately 1 mm noted floating in solution. No dose from this vial administered. Vial labeled ‘do not use’ and placed in pharmacy return bag per policy. Pharmacy notified. New vial obtained for ordered dose.”
- “0745 Prepackaged 10 mL NS flush found in medication drawer with outer wrapper torn at plunger end before use. Syringe not used for patient care. Syringe discarded per unit policy. New sealed flush used.”
How to chart when the doctor does not call back
- 14:00: New confusion; follows one-step commands but cannot identify location. BP 86/50 mm Hg, HR 124/min, RR 30/min with accessory muscle use, SpO₂ 88% on room air. At 13:30, patient was oriented to person, place, and time; BP 118/70, HR 88, RR 18, SpO₂ 96% on room air.
- 14:01: Urgent page placed through hospital operator to Dr. Patel, covering physician. Message included new confusion, BP 86/50, HR 124, RR 30, and SpO₂ 88% on room air; requested immediate bedside evaluation and callback to unit number. 14:03: No callback received.
- 14:01: Rapid response activated for hypotension, hypoxemia, and new confusion. Charge nurse Elena Lopez, RN, notified and at bedside at 14:02. Rapid response team and Dr. Chen arrived at 14:04; findings and unanswered page reported.
When the patient is sedated and nothing on the MAR explains it
- 1420: Pt found supine, eyes closed, snoring respirations. Did not open eyes to voice. Opened eyes briefly to sternal rub, then closed again. RR 7/min counted x 1 full min, SpO2 86% RA, pupils 2 mm bilat, sluggish.
- 0230: Pt difficult to arouse. Required repeated loud verbal stimulus and shoulder shake to open eyes. Speech slurred, falls back asleep mid-sentence. RR 10, SpO2 91% RA, BP 102/58, HR 64. FSBG 118.
- MAR reviewed: no opioid, benzodiazepine or sedating PRN documented since 0800. Dispensing cabinet record for this pt reviewed, no removals since 0800. Skin checked: one fentanyl patch, R upper arm, dated [date] per order. No other patches found. No medications found at bedside.
Orders, handoffs and other people
When bias changes who gives care
- 1505 Daughter [NAME] stated she did not want assigned RN [NAME] in room because RN is Black. Pt alert and oriented x3. Pt stated he accepts care from assigned RN. Daughter informed that care decisions are directed by pt. Charge RN [NAME] notified. Wound dressing changed by assigned RN at 1520. Pt tolerated well.
Documenting a chaperone during intimate care
- 0610 Patient requested female staff for peri care. Request honored. L. Rivera, CNA, provided peri care while this RN remained outside curtain and available for supplies. Skin intact; barrier cream applied by CNA. Patient calm, denied pain, call light within reach.
When a coworker seems impaired
- 1915 During transfer from bed to chair, assigned CNA staggered backward and released gait belt. This RN held gait belt and assisted patient back to edge of bed. Patient denied pain or dizziness; skin intact; no fall. Charge RN M. King notified at 1917 and came to room. Transfer completed with 2 staff at 1925.
- 2135 On MAR review, 2100 metoprolol showed not administered. BP 148/82, HR 78. Order and parameters verified. Metoprolol administered at 2138. Charge RN notified at 2140. Patient resting in bed, no distress noted.
- 2310 Controlled substance count for drawer 2 was incorrect by one tablet of oxycodone 5 mg during shift count with RN P.L. Medication record and waste log reviewed by this RN and RN P.L.; discrepancy not resolved at time of count. Charge RN and pharmacy notified at 2318 per policy.
Telling the family the resident has changed
- 1645: Called son (secondary contact) at home number on file. No answer. Left voicemail: identified self and facility, asked him to call back re: change in his father's condition, gave unit direct line. No clinical details left on voicemail.
- 1930: Son returned call. Informed of change and current plan as above. He states his sister is the POA and is out of town until Friday. He asked to be called first for any further change. Face sheet updated by supervisor at 1945 to list son as first call until Friday per his request; POA status unchanged.
- 1855: Unable to reach POA (see attempts 1650, 1700). Verbal report given to oncoming nurse K. Patel, who will attempt contact at 1900 and document. Supervisor aware.
When your assessment may become evidence
- Patient crying, hands trembling, respirations 24/min, speech clear, answered questions in short phrases. Patient stated exact words: [PATIENT EXACT WORDS].
- Skin assessment completed with patient permission. Left upper arm: 3 cm x 2 cm purple oval ecchymosis, tender to light palpation, skin intact. Right cheek: 1 cm superficial linear abrasion with scant dried blood. Body map completed.
- No visible injury noted to face, neck, chest, abdomen, back, hands, or external thighs during assessment at [TIME]. Patient declined assessment of [BODY AREA] at this time. Patient reports pain to [LOCATION], rated [NUMBER]/10.
What a nursing handoff note has to include
- 1845: BP 110/68, HR 88. Denies dizziness at rest. At 1745, developed dizziness when standing; assisted back to bed. See 1755 event note for assessment, provider communication, and interventions. Assisted ambulation remains in current care plan. Change and current status reviewed with A. Patel, RN, at 1900.
- 1900: CBC ordered for 2000; specimen not yet collected. A. Patel, RN, confirmed collection and result follow-up during handoff.
- 1840: Dr. Lee paged regarding urine output of 90 mL from 1500–1840. No response received by 1900. Charge RN M. Chen notified at 1855. Pending response and need for continued escalation under unit protocol reviewed with A. Patel, RN, at 1900.
When police ask for patient information
- 1610 Officer K. Nguyen, badge 455, delivered document titled subpoena addressed to medical records for ED visit dated 05/03/2026. Document sent to HIM/privacy office per facility policy. No records printed or released from ED by this RN. HIM confirmation received 1622. Charge RN aware.
- 1204 Officer M. Price requested IV fluids be delayed pending law-enforcement blood draw. Treating PA notified immediately. IV fluids administered at 1206 per existing medical order due to tachycardia and dehydration. Charge RN notified. No provider order received to delay fluids.
- 0830 During triage, officer at nurses station asked whether patient was present in ED. No patient condition, location, diagnosis, treatment, or discharge plan disclosed by this RN. Charge RN and security notified of request. Request referred to supervisor per facility policy.
Charting a patient's report of abuse by staff
- 0630 Patient declined male staff for bathing and transfer after reporting sexual touching by staff member on night shift. Patient stated she feels safer with female staff. Female RN and PCT assigned for personal care this shift. Patient accepted vital signs, medications, wound care, and breakfast setup from female RN.
The patient who came in with an officer
- Pt arrived 1415 accompanied by [AGENCY] Officer J. Ruiz, badge 4471. Officer states pt is under arrest. Officer remains at bedside.
- L ankle cuffed to bed rail by Officer Ruiz at 1420. Officer holds key. L foot warm, pink, cap refill <3 sec, pedal pulse palpable, pt denies numbness. Skin intact at cuff site.
- Per Officer Ruiz, pt struggled during arrest and struck head on pavement. Pt states he was pushed. 3 cm abrasion R forehead, no active bleeding. GCS 15. Dr. Patel notified 1430.
When another nurse tells you she gave something she never charted
- 1115 J. Smith RN verbally reported at nurses' station that she administered metoprolol 25 mg PO at approx 0900 and had not documented it. Not witnessed by this RN. eMAR shows 0900 dose not documented. Omnicell shows metoprolol 25 mg removed for this pt at 0852 by J. Smith. J. Smith states she will complete late entry.
- Per verbal report from off-going RN K. Lee at 1910, all 1700 meds administered. eMAR reviewed: 1700 insulin lispro not documented. K. Lee contacted at 1920, states dose given at 1705; she will enter late documentation. BG 1930: 142. Charge RN M. Diaz notified 1925.
- Day shift RN T. Ruiz stated in handoff at 1900 that she changed L heel dressing this AM; no documentation found in flowsheet. On assessment at 1945: dressing dated [date] with initials TR, clean/dry/intact. Asked T. Ruiz to document her dressing change.
When someone else says yes for the patient
- Consent obtained by phone from Maria Lopez, granddaughter, (555) 201-3344, at 1430.
- Son James Reed reached at 0915. States he is not the named agent; agent is daughter Ann Reed. Charge RN notified. Message left for Ann Reed at (555) 410-2210.
- Health care POA dated 11/12/2009 naming Maria Lopez as agent, copy in chart under Advance Directives tab, reviewed by this RN at 1430.
Documenting a verbal order and the read-back
- 09/12/2026 0915: Verbal order from Maya Chen, MD: acetaminophen 650 mg orally once now for headache. Complete order read back to Dr. Chen; confirmed correct. Received and entered by J. Rivera, RN.
- 09/12/2026 2030: Telephone order from Elena Brooks, NP: Complete blood count without differential on 09/13/2026 at 0600. Complete order read back to E. Brooks, NP; confirmed correct. Received and entered by J. Rivera, RN.
- 09/12/2026 1410: Telephone call with Maya Chen, MD, regarding acetaminophen. Dose unclear; call disconnected before clarification or confirmed read-back. No acetaminophen administered. Callback attempted at 1412; no answer. Charge RN notified at 1415; covering prescriber contacted for clarification. J. Rivera, RN.
Fixing a note, and who sees it
What the EHR audit trail shows about your charting
- Late entry entered 1040 for care provided at 0815: Patient reported headache 6/10. Acetaminophen 650 mg PO administered per PRN order. At 0915, patient reported headache 2/10.
- Correction entered 1540 to the 1500 assessment: SpO₂ was 98% on oxygen at 2 L/min via nasal cannula, not room air.
- 1110: Reviewed potassium result of 2.9 mmol/L, resulted at 0832. Dr. Chen notified by telephone at 1113; order received for potassium replacement.
Charting when you know you are being watched
- 0815 Son at bedside taking notes. Son asked purpose of furosemide. Reviewed medication name, ordered dose, indication listed in MAR, and common side effects. Patient accepted medication. No adverse reaction noted.
- 1902 Patient found short of breath with SpO2 84 percent on 2 L NC. Rapid response activated. Daughter standing near doorway holding phone with camera directed toward team. Charge RN asked daughter to move away from bedside. Oxygen increased to 6 L while awaiting provider. Patient transferred to ICU at 1935.
- 1530 Daughter stated she was recording staff interactions. No threats made toward staff at that time. Charge RN notified. Scheduled assessment and medications completed. Patient alert and oriented x3, respirations even, call light within reach.
You charted on the wrong patient
- Invalidate the wrong 1400 row; enter this patient's own vitals as a new row, flagged as a late entry if they're late
- Late entry for [care time]. Assessment: alert, oriented x4, lungs clear bilaterally, denies pain.
- Late entry for 0900: metoprolol 25 mg PO given at 0900. HR 72, BP 128/76 prior to administration.
What co-signing a nursing note actually means
- [DATE] [TIME] Addendum: Nursing student [NAME] documented assessment at [TIME]. I did not directly observe that assessment. I assessed patient at [TIME]: alert and oriented x4, respirations even and unlabored, lung sounds clear bilaterally, dressing to [SITE] dry and intact, pain [SCORE]/10.
- [DATE] [TIME] CNA [NAME] reported patient ambulated approximately 100 ft with front-wheeled walker at [TIME]. I did not directly observe ambulation. I assessed patient at [TIME]: seated in chair, denies dizziness, denies shortness of breath, call light within reach.
How to correct a nursing note you already signed
- 09/12/2026 0940: Correction to nursing note signed 09/12/2026 at 0910: The peripheral IV I inserted at 0900 was in the right forearm, not the left forearm. Left forearm was entered incorrectly in the original note. Correction is based on my recollection of performing the insertion. A. Lee, RN.
- 09/12/2026 1430: Addendum to admission note signed 09/12/2026 at 1330: At 1420, the patient’s daughter reported that the patient uses a walker for all ambulation at home. This information was not available when the admission note was signed. Receiving nurse J. Patel, RN, notified at 1425. A. Lee, RN.
- 09/12/2026 1800: Late entry for care provided 09/12/2026 at 1600, omitted from nursing note signed at 1615: At 1600, I assisted the patient from supine to the left side and placed a pillow between the knees. This entry is based on my recollection of providing that care. A. Lee, RN.
Charting the conversation after a medication error
- 06/10/2026, 1220: Bedside disclosure with patient, A. Patel, MD, hospitalist, and this RN. Daughter R. Chen participated by speakerphone at patient’s request. Dr. Patel led discussion.
- Glucose monitoring to continue per active orders. Dr. Patel stated he would return by 1400 to review results and provide an update on the daughter’s unanswered question about how the error occurred, including whether further review was still needed. Patient and daughter informed of planned update.
- Joined bedside discussion at 1228. Heard Dr. Patel review the glucose-monitoring plan and answer the patient’s question about symptoms to report. Initial explanation occurred before this RN arrived and was not witnessed by this RN.
How to chart something you are not sure about
- 1400: Left calf with approximately 4 × 3 cm area of redness, warmer than surrounding skin, and tenderness with light palpation. Cause not established. NP Patel notified at 1405 of findings; bedside evaluation requested.
- 1030: Patient states correct name but identifies hospital as home and cannot state month. Baseline orientation not yet verified. Dr. Chen notified at 1035 of findings and unknown baseline; assessment requested.
- 1340: Swelling around left forearm peripheral IV site; patient reports burning. Findings concerning for infiltration. Infusion stopped and site managed per facility protocol. Charge RN Lee notified at 1342; bedside assessment requested. 1350: Swelling unchanged; patient reports decreased burning.
What to do when an order looks wrong
- 0908: Concern remains about administering metoprolol with pulse 48/min and BP 92/54 mm Hg. Charge RN Patel notified of findings, Dr. Lee’s response, and dose not yet administered. Requested further clinical review. RN Patel contacting covering attending through unit escalation pathway.
- 0916: Dr. Lee entered order to hold morning metoprolol dose. Dose not administered; medication administration record updated. 0920: Pulse 50/min; BP 96/56 mm Hg. Patient denies dizziness.
- 1100 late entry for 0905 today: During telephone discussion with Dr. Lee, reported pulse 48/min and BP 92/54 mm Hg before scheduled metoprolol and requested dose review. Dr. Lee advised administering the ordered dose. This entry adds discussion details omitted from my earlier note.
When charting happened under the wrong login
- 1530 Addendum to 1500 flowsheet documentation: Vital signs obtained by [YOUR NAME], RN, at 1500: BP 128/76 left arm sitting, HR 84, RR 18, temp 98.4 F oral, SpO2 97% on room air. Values were entered under an incorrect user account; supervisor notified at 1525.
Keeping your own notes, texts and screenshots
- Chart late entry, if accurate: Late entry entered 09/13 at 09:15 for care at 02:10: BP 82/46; HR 122. Rapid response activated at 02:11. Dr. Lee notified by telephone at 02:12 and stated he was coming to bedside.
- Chart: 14:05 secure chat sent to Dr. Lee reporting new nausea after oral medication. No acknowledgment received by 14:15; office called. At 14:18, Dr. Lee returned call and stated he would review medication orders.
- Chart the relevant care facts instead: 10:00 patient declined scheduled acetaminophen, reporting pain 0/10. Medication not administered.
Your job, not the chart
Is a no-call no-show patient abandonment? What boards say
- 0710: RN Smith not present for scheduled 0700 shift. No report given to RN Smith and no patient assignment accepted by RN Smith. Charge RN redistributed Hall A assignments to RN Jones and RN Patel. Nursing supervisor Brown notified at 0712.
- 0542: I notified Charge RN Lee by phone that I am unable to report for the 0700 shift due to illness. I had not received report, accepted keys, or accepted a patient assignment for this shift.
- 1915: Bedside report for rooms 301-304 completed to RN Kim. MAR, pending labs, wound care due at 2200, and fall precautions reviewed. Charge RN Davis notified I am unable to accept additional 1900-2300 coverage.
Requesting time off as a nurse: getting the answer in writing
- Requesting PTO for 08/03/2026 0700-1930, 08/04/2026 0700-1930, and 08/05/2026 0700-1930 only. I am available to work 08/06/2026 and 08/07/2026 if scheduled. Please approve or deny in the scheduling system.
- Requesting not to be scheduled from 06/12/2026 at 1900 through 06/16/2026 at 0730. PTO requested for scheduled shifts during that period only. I am not requesting PTO for 06/10, 06/11, 06/17, 06/18, 06/19, or 06/20.
- Following our conversation today at 1430, I am submitting this written PTO request for 09/14/2026 0700-1930 and 09/15/2026 0700-1930. Please confirm approval or denial by email or in the portal.
Floating to another unit: what you can refuse and what to document
- 1845 Floated from Postpartum to ED. No prior ED orientation. Asked charge RN J. Green for location of code cart, medication room, clean supply, glucometer process, emergency call process, and assigned resource nurse. Unit walk-through completed with K. Brown, RN at 1855. Resource RN for shift: K. Brown, RN.
- 2130 Vancomycin due. Medication not available in unit Pyxis. Requested medication from pharmacy at 2135 and notified charge RN at 2140. Medication received at 2210 and administered at 2215 per MAR. Patient tolerated infusion without reaction.
Risk management asked to talk: what that meeting is
- 1905 On initial assessment, left forearm PIV site swollen approximately 4 cm, cool to touch. Patient reports pain 6/10 at site during infusion. Infusion stopped. PIV removed, catheter intact. Arm elevated. 1915 Charge RN [NAME] notified. New PIV placed right hand at 1930.
- 0900 Scheduled cefazolin not available in Pyxis. 0903 Pharmacy notified of missing dose. 0942 Dose delivered to unit. 0945 Cefazolin administered IV per MAR. Patient tolerated without adverse reaction. [PROVIDER NAME] notified of delayed administration at [TIME].
- 1510 Foley catheter noted out of patient with balloon deflated in bed. Small amount of blood noted at meatus. Patient reports catheter came out while standing to transfer to chair. VS: [VS]. Perineal care provided. [PROVIDER NAME] notified at [TIME]. Order received to [ORDER].
Job hunting as a nurse: non-competes, references and what you can take with you
- Room 418, [PATIENT NAME], MRN [MRN], septic shock case from [DATE]. Used Levophed, central line, rapid response, ICU transfer. Good interview example.
- Dr. [NAME] can talk about the patient in 6B and how I handled that code.
Answering the discipline question on a license application
- Pennsylvania State Board of Nursing, Consent Agreement dated 03/14/2019, case no. 19-51-0123. Two years probation for a documentation error. Probation completed 03/14/2021. Certified copy of order attached.
- Terminated by [EMPLOYER], [CITY, STATE], on 06/02/2023 after a medication count discrepancy on my unit. No board complaint was filed to my knowledge. Termination letter attached.
- Arrested 08/10/2020, [COUNTY] County, charged with DUI (misdemeanor). Entered a pretrial diversion program; completed 08/2021; charge dismissed 09/2021. Court disposition attached. Disclosed because the question asks about any arrest, regardless of outcome.
Nurse named in a malpractice suit: what happens to your notes and what to do first
- 0900 Scheduled furosemide 40 mg PO not available in patient drawer or Pyxis. Pharmacy refill request sent 0903. Medication received 0947 and administered 0952. Patient denied shortness of breath before administration. BP 132/70, HR 82.
- 2215 Provider [NAME] notified by phone of temperature 101.4 F, HR 104, BP 118/64, RR 20, SpO2 95 percent RA, and patient report of chills. Provider gave order for acetaminophen 650 mg PO once and urine sample if patient voids. Order read back and entered. Acetaminophen given 2225.
Calling out for a sick child: FMLA, what to say, and what to keep
- 05/14/2026 0520: Called staffing office at 555-0100. Spoke with T. Lee. Reported unable to work 0700-1930 shift on 4E due to need to care for sick child. Requested use of sick or caregiver leave if available. T. Lee stated absence entered as unscheduled call-out.
- 05/14/2026 0522: Sent message to charge nurse A. Patel after calling staffing office. Message stated unable to report for 0700-1930 shift due to sick child and that staffing office had been notified. Screenshot saved.
- I am calling out for the full 0700-1930 shift today. I will update staffing by 1500 only if policy requires additional follow-up.
Resigning as a nurse: notice, what to put in writing, what happens after
- Please accept this letter as my resignation from my position as RN on 4 West. My last day of work will be Friday, October 24, 2026. Thank you for the experience I gained on this unit.
- My last scheduled shift will be October 24, 2026 (0700–1930). I will complete all shifts currently on the schedule through that date.
- Following our meeting today, 10/10/2026 at 1400, I am confirming my resignation with a last day of 10/24/2026. My signed letter was handed to you at the meeting. You said you would check with HR on my PTO balance and let me know.
Unpaid meal breaks and off-the-clock work for nurses: what records win
- Missed meal correction: scheduled meal period 1230–1300 not taken. Remained responsible for Rooms 421, 423, and 424 due no relief nurse available. Gave scheduled meds, answered call lights, and took provider call during that time. Charge RN M. Lee notified at 1228 and 1306.
- Meal break interrupted at 1242 when Room 418 bed alarm sounded. Returned to patient care from 1242–1310. Assisted patient back to bed, completed fall-risk reassessment, notified charge RN at 1312. Uninterrupted 30-minute meal period not received.
- Time correction request: clocked out at 1930, but required handoff and nursing documentation continued until 1956. Handoff for Rooms 410, 412, and 414 completed 1930–1944. MAR reconciliation and nursing notes completed 1944–1956. Charge RN notified at 1957.
Writing a statement for a hospital investigation: what belongs in it
- 0705 Initial assessment completed. Patient supine in bed. Sacral dressing dated [DATE] intact with 2 cm serosanguineous drainage visible on dressing. Turn sheet showed last documented repositioning at 0200. Patient repositioned to left side with pillows at 0715. Skin warm and dry. Wound nurse notified per unit process.
- Cefazolin dose due at 0900. Medication not available in Pyxis at 0855. Pharmacy message sent at 0856. Medication delivered to unit at 0940 and administered at 0945. Provider notified at 0950 of delayed dose. Patient remained afebrile at 1000.
- Patient stated: night staff hit my arm. Patient alert and oriented to person, place, and time during statement. Left forearm assessed. 2 cm purple discoloration noted on posterior forearm; skin intact. Charge RN notified at 0810. Patient remained in room with call light within reach.
A patient assaulted you: reporting and documenting it
- At 1914, during medication administration, patient struck this RN on the left upper arm with right closed fist x1. This RN stepped back and called for staff assist. Charge RN and security arrived at 1915. Patient remained standing at bedside, yelling, and did not fall. Provider notified at 1918.
- At 2230, during hygiene care, patient kicked toward MHT with right leg x2 and contacted MHT’s left thigh x1. Care paused. Two staff remained at doorway. Patient was offered gown change or bath wipes later. Patient accepted bath wipes at 2245.
- At 0710, patient was sitting on edge of bed. This RN reached toward bedside table to move water cup. Patient swung right fist and contacted this RN’s left forearm x1. No staff physical contact with patient occurred immediately before the strike.
Nurse corrective action and write-ups: what to sign, what to add, what to keep
- Patient chart: 2204 oxycodone 5 mg PO administered for incisional pain 7/10 after two patient identifiers verified. Barcode scanner unavailable; downtime medication process used per policy. MAR updated at 2220 when workstation access restored. Pain reassessed at 2305: 3/10. Charge RN notified of scanner issue at 2200.
- HR response or email, not the patient chart: On 03/18 at 1645, I was asked to review my 1200 assessment note for accuracy. I reviewed the note at 1700. The documented assessment matched my findings at that time. I did not enter an addendum because I had no additional patient-care information to add.
- Patient chart: 1000 patient declined repositioning and hygiene care, stating no, not now. Education provided on skin protection and comfort. Call light within reach. 1030 patient accepted partial bath and repositioning to right lateral. Skin intact on visualized areas.
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shiftiswild.com/sheets/charting-lines/ · written by a med-surg RN, ten years, day shift