LISTEN UP NPs and RNS Never use these words in your documentation

@itskikibabez

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Promoted product

Chart Like a Lawyer

Professional & Technical · 2025

4 videos

Why it worked

The video addresses a high-stakes professional pain point (legal liability for nurses) and provides immediate, actionable value by showing exactly what to write instead of common mistakes.

Summary

The creator reviews a book titled "Chart Like a Lawyer" by Jaime Weiland, demonstrating how it provides objective charting templates for nurses to avoid legal issues. She highlights specific examples from the book and encourages viewers to purchase it if available.

Structure

1Identify common charting mistakes
2Explain why these words are legal risks
3Provide objective alternatives
4Introduce the book 'Chart Like a Lawyer'
5

Original caption

This book breaks down common charting mistakes and what to say instead. Protect your license, one note at a time! 📚 #NurseTok #NursingTips #NurseLife #NursingDocumentation #ChartLikeALawyer

More from @itskikibabez

Product placement

(a) "Chart Like a Lawyer" by Jaime Weiland — the book is held, opened to specific pages, and its content is used to demonstrate how to improve nursing documentation. It acts as the primary source of the advice and templates provided. Removing it would change the video as it is the specific product being recommended.

Call to action

If you want to grab a copy of this, I'm going to try to link it in my video if they're still available.

On-screen text

LISTEN UP NPs and RNS Never use these words in your documentation AVOIDING LOADED WORDS AND LEGAL TRIGGERS Certain words instantly draw attention in litigation because they imply error, neglect, or attitude. Avoid these charting landmines: Forgot Neglected Mistake Oops Refused care (without context) Non-compliant Uncooperative Combative Hostile Replace with: Omitted due to... Delay caused by... Patient declined care after education... Patient exhibited aggressive tone and movements... PRACTICAL TOOLS: THE 3R FRAMEWORK FOR NEUTRAL DOCUMENTATION LEGAL PEARL: YOU CAN'T CONTROL A LAWYER'S NARRATIVE—BUT YOU CAN CONTROL YOUR LANGUAGE. USE WORDS THAT PROVE CALM, COMPETENCE, AND CLARITY. CHAPTER 3 - Charting Facts, Not Feelings OBJECTIVE LANGUAGE PROTECTS YOU SUBJECTIVE OR RISKY LANGUAGE Patient acting weird. Patient rude and uncooperative. Seems confused. Appears comfortable. OBJECTIVE, DEFENDABLE ALTERNATIVE Patient pacing room, speaking rapidly, stating 'I can't calm down.' Patient raised voice and refused vitals; education provided on importance: patient verbalized understanding. Disoriented to time; asked where he was twice within 5 minutes. RR 14, even, unlabored; eyes closed; no grimacing or restlessness observed. ABOUT JAIME WEILAND CHAPTER 10 - Real-World Templates and Smart Phrase 1. ADMISSION AND HAND-OFF SMART PHRASES Template - "NEWADM" Admitted to [unit] for [diagnosis]. Arrived [method]. A&O x []. calm, cooperative. Vitals stable, no acute distress. Safety measures initiated (bed low, rails, alarm). IV [site], [patent]. Orientation complete. Provider notified, orders reviewed.

Transcript

LISTEN UP NPs and RNS. Never use these words in your documentation. Certain words instantly draw attention in litigation because they imply error, neglect, or attitude. Avoid these charting landmines: Forgot, Neglected, Mistake, Oops, Refused care (without context), Non-compliant, Uncooperative, Combative, Hostile. These are actually legal triggers and you can get in trouble because they imply error, neglect, or you were having an attitude. Instead, replace it with: Omitted due to, Delay caused by, Patient declined care after education, Patient exhibited aggressive tone and movements. Instead of charting subjectively, you have to chart objectively. Instead of saying appears comfortable, you would say respiratory rate 14, even and unlabored, eyes closed, no grimacing or restlessness observed. The book I'm reading from is actually written by a legal NP. Not only does it give you real-life examples of when charting went wrong and when charting went right, but it also gives you real-world templates and smart phrases that you can actually use in the job. And I'm not even going to lie, this admission template is actually so good. If you want to grab a copy of this, I'm going to try to link it in my video if they're still available. They have been selling out pretty fast. I had to wait for mine to come back in stock for me to grab it.