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What to write when it goes wrong
75 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 — 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.
How a note is read
Signing an AI-drafted nursing note
- 1930 Pt awake in bed watching TV. Reports incisional pain 6/10. Lungs clear bilaterally. Abd soft. RLQ dressing dry and intact. Acetaminophen 650 mg given per MAR at 1940. Bed low/locked, call light in reach.
- 0815 BP 178/96 L arm, HR 88. Pt denies chest pain, SOB, headache, or vision changes when asked. Manual recheck at 0822 BP 172/94. Provider Lee notified by secure chat at 0828. New order received for hydralazine 10 mg IV once.
- 1010 Pt reports nausea after breakfast, no emesis. Ondansetron 4 mg IV given per MAR. 1045 Pt reports nausea improved and tolerated sips of water.
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.
Charting by exception and the risk of WNL
- 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.
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.
Time, and what it proves
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.
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 it goes sideways
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.
Documenting isolation precautions and refusals
- 0835 Contact and Droplet Precautions initiated after RSV PCR resulted positive at 0828. Isolation sign posted, PPE cart stocked at doorway, dedicated stethoscope placed in room. Patient and mother instructed on hand hygiene, mask use for transport, and visitor PPE. Charge RN notified.
- 1410 Isolation updated from Droplet/Contact to Airborne/Contact per facility aerosol-generating procedure before nebulized treatment. Patient moved to AIIR room 412. N95, eye protection, gown, and glove signage posted. RT and charge RN notified. SpO2 95% on room air, no acute distress.
- 0720 Airborne Precautions initiated per provider order for rule out pulmonary TB after hemoptysis and abnormal chest imaging. Patient placed in negative-pressure room 606, door closed, N95 signage posted. Patient instructed to wear surgical mask for essential transport only. Charge RN notified.
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.
How to document short staffing and unsafe assignment
- 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.
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.
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.
Other people in your chart
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.
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.
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.
When it already happened
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
- 0910 — Daughter asked when next glucose check was due. Reviewed scheduled monitoring plan with patient and daughter. Daughter requested an update after the next check.
- 1410 — Daughter reported patient had requested toileting assistance approximately 20 minutes earlier. Patient confirmed need to toilet. Assisted patient to bedside commode with one-person assist and returned patient to bed. Call light placed within reach.
- 1015 — Daughter stated she was recording during preparation for catheter care. Patient requested no recording. Kept patient covered and paused preparation while charge RN assisted with privacy concern. Daughter put phone away; patient agreed to proceed. Catheter care completed at 1020.
What co-signing a nursing note actually means
- 1435 — Correction to consent documentation entered at 1405: I was not present when the patient signed. My witness signature was entered in error. Charge RN and procedural team notified at 1430; consent verification remains pending.
- 1420 — Correction to 1410 consent entry: I observed the patient sign the form. I was not present for the practitioner’s consent discussion. After signing, patient asked about nonsurgical options. Dr. Patel notified at 1415; further consent discussion requested.
- 0945 — Correction to 0900 co-signature: I reviewed the student’s note but did not observe the 0845 assessment. My earlier attestation of direct supervision was incorrect. My assessment at 0930: respirations 18/min, unlabored; SpO₂ 96% on room air.
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.
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.
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shiftiswild.com/sheets/charting-lines/ · written by a med-surg RN, ten years, day shift