Why you should never document “Patient stable, no distress noted”

@itskikibabez

8.4K followers · usually 982 views a post

Views

119.8K

Likes

6.9K

Comments

34

Shares

326

SoundTikTok sound · original sound - itskikibabez

Promoted product

Chart Like a Lawyer

Professional & Technical · 2025

4 videos

Why it worked

The video uses a high-stakes professional fear (losing a nursing license) to create immediate urgency, then provides a concrete, actionable solution that directly addresses that fear.

Summary

A nurse explains why documenting vague phrases like 'patient stable' can lead to legal issues and recommends a specific book, 'Chart Like A Lawyer', as a resource for improving nursing documentation. She demonstrates the book's content and encourages viewers to purchase it to protect their professional licenses.

Structure

1Identify a common nursing documentation error
2Explain the legal risks of vague charting
3Introduce the book as a solution
4Highlight specific features and benefits of the book

Original caption

Your documentation could be the thing that protects your nursing license 🩺 Don’t wait until you’re questioned to learn how to chart correctly #NurseTok #NursingTips #NurseLife #NursingDocumentation #ChartLikeALawyer

More from @itskikibabez

Product placement

Chart Like A Lawyer (book): (a) ACTS — the creator holds it, shows specific pages, reads from it, and explains how it teaches nurses to document correctly to protect their licenses. Removing it would change the video entirely as it is the subject of the recommendation.

Call to action

I'm going to try to link it in my video.

On-screen text

Why you should never document “Patient stable, no distress noted” CASE FILE #5—“STABLE” PATIENT WHO WASN’T The Situation: Nurse charted ‘Patient stable, no distress’ before cardiac arrest. What the Jury Saw: No vitals or descriptors recorded. The Plaintiff Attorney’s Argument: She wrote ‘stable’—by what standard? How It Could Have Been Documented: 2245: Resting in bed, conversing, no distress. Vitals 108/66, HR 82, RR 16, SpO2 97% 2L. No chest pain, dizziness, or SOB. Lesson: Avoid vague adjectives; use data instead. Protect your license with good documentation

Transcript

Why you should never document “Patient stable, no distress noted”. The nurse charted “Patient stable, no distress” before a cardiac arrest. She didn't document any vitals and there were no descriptors recorded. Instead she could have said the time, resting in bed, conversing, no distress. Vitals, the vital signs, no chest pain, dizziness or shortness of breath. This book is filled with information on how to chart correctly and my favorite part is that it comes with real-world templates and smart phrases that you can use at work. I got this book so I can improve my documentation and protect my license, but they have been selling out. The book is written by a legal NP and in this book you're going to learn how to document a way that actually protects you in court, avoid the most common charting mistakes seen in lawsuits, show clinical judgment, escalation and reassessment in your notes, navigate high-risk situations, it does talk about the five high-risk situations, and understand how your documentation impacts billing, quality metrics and liability. The only problem is that they have been selling out. I did get mine and they are back in stock, so if you want to grab one I'm going to try to link it in my video.