Documentation Red Flags

10 Documentation Red Flags Every Nurse Manager Should Know

(And what to do when you see them)

Poor documentation doesn’t always look like a crisis.

Sometimes it hides in the routine.

Here’s what I’ve seen over my 15 years on real audits:

🚩 Copy-paste notes with no reassessment

🚩 No documentation of escalation

🚩 Vague language like “fine” or “resting”

🚩 Long gaps in notes for unstable patients

🚩 No handover or end-of-shift summary

🚩 Missing signatures or timestamps

🚩 Notes written hours after the shift

🚩 Patient “drowsy” in note, “alert” in flowsheet

🚩 No pain score, no vitals, no neuro checks

🚩 “Refused care” with zero explanation

These aren’t just errors.

They’re patterns.

And patterns create liability.

I built a Red Flag Checklist for nurse leaders who want to reduce risk and improve team accountability.

It’s bite-sized.

Audit-tested.

Made by a nurse, for nurses.