From our deposition videos
Each one makes sense at 0300. Two years later a lawyer reads it out loud and asks what it means. Here is what to write instead.
What lawyers and experts have actually asked about these phrases, with the cases: On the stand.
Patient fell.
Did you see it? If nobody saw it, "fell" describes something you did not witness.
Write instead
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.
No injury noted.
What did you check? It is a conclusion. It does not show the assessment behind it.
Write instead
Head-to-toe: no lacerations, bruising, or swelling noted. Moves all extremities, full ROM without pain. Pt denies hitting head. Pain 0/10.
MD aware.
Aware of what, and since when? It does not say who you reached, what you told them, or what they said back.
Write instead
1410: Paged Dr. Lee regarding urine output of 20 mL over past 2 hours. Separate later entry: 1420: Spoke with Dr. Lee; reported urine output and BP 118/70. No new orders received.
Patient refused.
Refused what? It hides which care you offered, the patient's reason, and who you told.
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0900: Scheduled enoxaparin 40 mg subcutaneous offered. Patient declined, reporting painful bruising after previous injections. Dose not administered. 0910: Dr. Chen notified of refusal and patient's reported concern.
Noncompliant.
With what? It labels the patient without naming the decision or the barrier.
Write instead
1400: Patient declined full left-side turn, reporting left hip pain 7/10 and requesting pain medication before repositioning. Accepted a small assisted weight shift and heel off-loading.
Tolerated well.
Tolerated what? How well? It does not say what you assessed.
Write instead
Walked 30 feet; denied dizziness or dyspnea; gait steady with walker.
Patient fine.
Fine how? It tells the reader nothing about what you assessed.
Write instead
0100: Awake; answers questions appropriately. Respirations 16/min and unlabored. Denies shortness of breath.
Will continue to monitor.
Did you? It is a plan, not care. The checks have to show up later, each with a time.
Write instead
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.
These are illustrative entries, not real patients and not excerpts from court cases. Chart only findings and actions that actually happened; better wording is no substitute for an honest account. Follow your facility's policy. Nothing here is legal advice. More pocket lines: What to write when it goes wrong.