# Charting by exception in litigation: WDL, blanks and AI review > Charting by exception in nursing negligence cases: what WDL and a blank flowsheet cell mean, Lama v. Borras, what to request, and where AI review helps. Canonical page: https://medrecords.ai/guides/charting-by-exception/ --- New — **Missing Records Detection:** flags every visit, provider, and date missing from the file. [See how →](https://medrecords.ai/product/missing-records-identification/) Field guide, September 2026. 14 chapters. ## Charting by exception: how to read WDL entries and blank flowsheet cells in a nursing negligence case For plaintiff and defense med-mal attorneys, legal nurse consultants and nurse experts working a chart built on flowsheets. You walk away with the rules, the only well-known appellate case, a method for reading a blank cell, and 4 templates: a discovery request, 30(b)(6) topics, a gap log and a nurse deposition outline. By [Ahmed Jemaa](https://medrecords.ai/authors/ahmed-jemaa/), Co-Founder and CEO, Medrecords AI. Published 25 September 2026. Charting by exception is a nursing documentation method in which nurses chart only findings that depart from written, facility-defined normal parameters, so a checkmark or WDL entry means the patient met that definition. In litigation a WDL or blank cell cuts both ways: it can mean assessed and normal under policy, or never assessed. The policy, the defined normals and the assessment frequency in effect that day decide which reading holds. A nursing flowsheet is a grid of checkmarks, WDL entries and empty cells, and in a negligence case every empty cell turns into an argument. Under charting by exception the facility promised that silence means normal. The plaintiff says silence means nobody looked. The flowsheet alone settles nothing. This guide is built from the First Circuit's opinion in *Lama v. Borras*, 16 F.3d 473 (1994), Federal Rules of Evidence 406, 803(6) and 803(7), Federal Rules of Civil Procedure 30(b)(6) and 34, the hospital Conditions of Participation at 42 CFR 482.23 and 482.24, the nursing home assessment rule at 42 CFR 483.20, and 3 peer-reviewed studies: Collins et al. on nursing documentation and mortality (American Journal of Critical Care, 2013), Wang, Khanna and Najafi on copied text in progress notes (JAMA Internal Medicine, 2017), and Alderden et al. on the Braden scale (2017). The worked example is hypothetical. Nothing here is legal or medical advice. Evidence, discovery, privilege and nursing practice rules vary by state. 8 numbers ### Charting by exception in 8 numbers $600,000 compensatory verdict affirmed in the best-known charting by exception case Lama v. Borras, 16 F.3d 473 (1st Cir. 1994) 24 to 72 hrs delay in treating the infection that the Lama jury could reasonably infer 16 F.3d 473, part III.C 3 conditions for using the absence of an entry to prove something did not happen FRE 803(7)(A) to (C) 30 days to answer a federal request for production, unless changed by stipulation or order FRCP 34(b)(2)(A) 14 days after admission for a nursing home's first comprehensive resident assessment 42 CFR 483.20(b)(2)(i) 15 months of resident assessments a nursing home must keep in the active record 42 CFR 483.20(d) 46% of the text in a typical inpatient progress note was copied, 23,630 notes Wang et al., JAMA Intern Med, 2017 6.1 to 10 more vital signs charted in 48 hours for patients who died than for survivors Collins et al., Am J Crit Care, 2013 Chapter 1 Everyone ### What charting by exception is, and what it is not Charting by exception (CBE) is a bargain. The facility writes down in advance what "normal" means for each part of a nursing assessment: lungs, heart, neuro, skin, pain, sedation, the wound. If the patient meets that standard, the nurse marks the row with a checkmark or "WDL" and moves on. If not, the nurse charts the finding in detail. That entry is the exception, and it is the only narrative the system asks for. An early description, "Charting by exception: meeting the challenge of cost containment" (Murphy, Beglinger and Johnson), ran in *Nursing Management* in 1988. Electronic flowsheets made the idea standard, and most inpatient nursing documentation you read in discovery is now a flowsheet grid, whatever the policy is called. So the useful question is rarely "did this hospital use CBE?" It is "what did each mark and each blank mean under the policy that governed this unit on this date?" #### The vocabulary you need before the first deposition WDLWithin defined limits. The finding met the facility's written definition for that row. WDL points at a document. WNLWithin normal limits. Older and looser, often with no written definition behind it. When a chart says WNL, ask whose normal. Defined normal (parameters)The written standard for a row, for example "respirations 12 to 20 a minute, regular, unlabored". It may live in a policy binder, in EHR hover text that never prints, or both. Flowsheet row1 line of the grid: a body system, a scale score, a vital sign. Each row has an EHR build definition with its allowed values and any help text. Exception noteThe narrative a nurse writes when a finding departs from the defined normal, often linked from an asterisk, "see note" or comment icon. Assessment frequencyHow often a row must be reassessed, set by policy, protocol or order. The single most important number in a CBE case. Focused reassessmentA narrower recheck of 1 system between full assessments, often after a medication or procedure. Copy forwardAn EHR feature that carries the last value into the next column. A copied WDL looks exactly like a fresh one on paper. Device-validated valueA number that flowed from a monitor and was accepted by a nurse. It proves the monitor read something, not that anyone looked at the patient. #### What CBE is not CBE is not permission to skip assessments. It covers documentation of normal findings only. The assessment still has to happen at the required frequency, and a changed condition still has to be charted and, where policy or the standard of care calls for it, reported to a provider. If you remember one thing A WDL mark points to a written definition. Without the version in force on the date of care, you do not know what the mark says. Chapter 2 Everyone ### The rules a flowsheet is measured against No federal regulation permits or forbids charting by exception. Experts measure a CBE chart against general record and nursing rules, then the facility's own policy, then the standard of care. "All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures." Plaintiffs quote "complete". Defendants quote "consistent with hospital policies and procedures". The regulation defers to the policy, which is why the policy is the case. The nursing Condition of Participation makes that policy binding on the nurses: "All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital." If the policy says sedation is reassessed every 2 hours on a patient-controlled analgesia pump, a 4-hour gap departs from a rule the hospital wrote for itself, before any expert speaks to the standard of care. | Source | What it requires | How it is used in a CBE case | | --- | --- | --- | | 42 CFR 482.24(c) | Entries legible, complete, dated, timed and authenticated; the record describes the patient's progress and response to medications and services | The baseline for any Medicare-participating hospital. "Progress" is hard to square with 12 hours of checkmarks before a crash | | 42 CFR 482.23(b)(4) and (b)(6) | A current nursing care plan for each patient; nurses must follow hospital policies and procedures | Makes the policy's frequencies and definitions enforceable against the facility's own staff | | 42 CFR 483.20 | Nursing homes: comprehensive assessment within 14 days of admission, quarterly review at least every 3 months, annual reassessment, 15 months kept in the active record; "The assessment must accurately reflect the resident's status." | Long-term care shift charting sits under these assessments. Willful false certification carries civil money penalties, capped per assessment at $1,000 and $5,000 before inflation adjustment | | Facility documentation policy | The defined normals, the frequency of each assessment, what a blank means, how exceptions are charted and reported | The document the whole dispute is about. Request every version (chapter 9) | | Physician orders and protocols | Frequencies for a specific patient, such as neuro checks every hour | An order can set a tighter frequency than the policy; the tighter one governs | | State nurse practice act and board rules | Scope of practice, delegation, often a duty to document accurately | Varies by state. A nurse expert ties the chart to it | [](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.24) [](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.23) [](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.20) Joint Commission standards and professional guidance also get cited, but their wording changes by edition, so get the version in effect from your expert. A nursing home chart also has a federal assessment calendar that a hospital chart lacks, which gives you fixed dates to check. If you remember one thing The federal rules defer to the facility's policy, and 42 CFR 482.23(b)(6) binds the nurses to it. Get the policy and you have the yardstick. Chapter 3 Deciding ### Why a blank or WDL cell cuts both ways "Not documented, not done" is a teaching maxim, not a statute or rule of evidence. It captures a jury intuition: a careful professional would have written it down. CBE is built on the opposite premise. A nurse who found everything normal was told not to write it down. Rule 803(6) admits regularly kept business records. Rule 803(7) lets a party use the absence of an entry as proof: "Evidence that a matter is not included in a record described in paragraph (6) if: (A) the evidence is admitted to prove that the matter did not occur or exist; (B) a record was regularly kept for a matter of that kind; and (C) the opponent does not show that the possible source of the information or other circumstances indicate a lack of trustworthiness." Condition (B) is where CBE changes the analysis. Under CBE, the regular record of a normal finding is the checkmark, and of an abnormal finding the exception note. That produces 2 arguments from the same rule: - **A blank where the policy required a mark** (a row due at 03:00 with nothing in it) fits condition (B) well: the facility regularly recorded that assessment, and it is not there. - **The absence of an exception note** fits condition (B) for the defense: the facility regularly recorded abnormal findings, none is recorded, so the argument goes that nothing abnormal was found. Rule 406 then lets either side offer routine practice: "Evidence of a person's habit or an organization's routine practice may be admitted to prove that on a particular occasion the person or organization acted in accordance with the habit or routine practice." This is the defense's bridge across a blank cell: "I always assess every 2 hours on a PCA patient." Whether that is admissible habit is a fight for the evidence motions. Many states have their own versions of 406 and 803(7) with different wording. #### What a blank means under each system | Entry on the page | Under narrative charting | Under charting by exception | What settles it | | --- | --- | --- | --- | | Blank cell at a time an assessment was due | Strong "not done" inference | Still a gap. CBE covers normal findings, not missed assessments | The policy's definition of a blank, the frequency rule, other time-stamped sources | | Blank cell between required assessments | Nothing missing | Nothing missing | The frequency rule and any orders | | WDL or checkmark | Rare; a sign of a hybrid form | Assessed and met the written definition | The definition in force that day, filed times, copy-forward settings | | No narrative note for the shift | Suspicious | Normal if all rows were WDL; suspicious if any row was an exception | Any asterisk or comment with no linked note | | Exception note with no provider notification | Weak note | Weak note, and may breach the policy's escalation rule | Notification criteria, paging and call logs | | Identical values across many shifts | Copied text, easy to spot | Stable patient or copy forward; identical on paper | EHR metadata on how each value was entered | MythUnder CBE, a blank always means normal. RuleOnly if the policy says so. Many policies require a mark at each due time; a blank at a due time is a gap under the policy's own terms. MythLama v. Borras held CBE negligent. RuleIt affirmed a verdict where the hospital did not contest that its CBE practice broke a Puerto Rico regulation (chapter 4). MythA WDL mark proves an assessment happened. RuleIt proves someone filed a value. Copy forward, batch charting and device-validated values can all produce a WDL with no bedside look behind it. If you remember one thing Ask 2 questions every time: was an assessment due, and what did the mark mean? A blank only helps the plaintiff at a due time. Chapter 4 Deciding ### Lama v. Borras: what the court held, and what it did not Every article on CBE and the law cites *Lama v. Borras*, 16 F.3d 473 (1st Cir. 1994). A 1994 nursing-law newsletter ran it as "Court holds 'charting by exception' policy negligent," and that framing stuck. The opinion is narrower and more useful. **The Lama chart, as the First Circuit recounted it** — 1986 — 16 F.3d 473, part I and footnote 3 1. Apr 9 **First surgery** A neurosurgeon operates for a herniated disc and finds an extruded disc. The original symptoms return within days. Part I, para 4 2. May 15 **Second surgery** No pre- or post-operative antibiotics ordered. Part I, para 5 3. May 17 **"Very bloody" bandage** A nurse's note records it. An expert testified this indicates possible infection. Part I, para 5 4. May 18 **Local pain at the incision** Another symptom consistent with infection. Part I, para 5 5. May 19 **Bandage "soiled again"** The last scattered entry before the crisis. Part I, para 5 6. May 17 to 20 **What the chart could not show** No qualitative observations each shift under CBE. Temperature and vital signs were recorded; no fever appears before May 21. Part I, para 5; footnote 3 7. May 20 **Severe back pain overnight** The patient spends the night in severe pain. Part I, para 6 8. May 21 **Discitis diagnosed, antibiotics started** Months of further hospitalization follow. Part I, para 6 The temperature and vital signs were there. The qualitative trend (the wound, the pain) was not, and the jury could find that gap delayed treatment. #### What the court actually decided The jury returned a $600,000 compensatory verdict against the surgeon and the hospital, and the First Circuit affirmed the denial of judgment as a matter of law. On the hospital, 4 points carry the holding: 1. **Duty and breach were conceded.** The hospital did not contest that a 1986 Puerto Rico Department of Health regulation required qualitative nurses' notes each shift, or that its nurses followed the CBE policy instead. The regulation was not even in the appellate record (footnote 10). 2. **Causation was the only live question.** The judge instructed that violating a regulation "is not in itself enough to constitute negligence absent proof of the existence of the proximate cause" (footnote 11). 3. **The evidence of what went unrecorded was specific.** A former nurse testified that under the policy she would not chart pain if she gave no medication or only an aspirin-type drug. 4. **The delay was quantified.** The jury could infer a delay of at least 24 hours and perhaps 72, and an expert testified that 24 hours can make a difference in controlling an infection. "... the jury could have reasonably inferred that intermittent charting failed to provide the sort of continuous danger signals that would be the most likely spur to early intervention by a physician." #### How to read it For plaintiffs, *Lama* is the cleanest statement of the CBE causation theory: charting only exceptions can hide a trend, and a hidden trend can delay the physician. It is also a model of proof: a regulation, a witness who described what the policy let nurses leave out, and a timeline that turned the gap into hours of delay. For defendants, *Lama* is weak authority against CBE as such. It is 1 federal appellate case applying Puerto Rico law, on the deferential standard for overturning a verdict, and the breach rested on a regulation the hospital did not dispute. The court agreed with the trial judge that the case was "by no means the strongest proposition for medical malpractice against ... a hospital." A modern flowsheet with written definitions, frequent reassessment and escalation rules is a different system from the 1986 practice. We did not find a later published appellate opinion on charting by exception that we could verify. If opposing counsel cites one, read the opinion, not the summary. If you remember one thing *Lama* is a causation case. A witness explained what the policy left out and an expert tied the gap to hours of delay. Build your case, on either side, the same way. Chapter 5 Building ### How to read a charting by exception flowsheet Printed flowsheets were designed for a screen, then flattened onto paper by a print routine nobody in the courtroom has seen. The mock page below shows the 7 things to check on every page before you draw an inference from a blank. Flowsheet: adult assessment Printed view, hypothetical Columns 01:00 | 03:00 | 04:12 | 05:00 Time header — 01:00 (filed 01:08)1 Respiratory — WDL | (blank) | (blank) | (blank)2 SpO2 — 93% | (blank) | 91% (V) | (blank)3 Sedation score — 2 | (blank) | (blank) | (blank)4 Skin — WDL (previous value)5 Comment — * see note 05:406 Filed by — RN-A, RN-A, device7 HOSP 000213 1. 1 **Assessment time vs filed time** The header is when the nurse says the assessment happened. If the print does not show filed time, the metadata does. A 01:00 column filed at 06:30 is a late entry. 2. 2 **WDL points to a definition you cannot see** It lives in the policy or EHR hover text and almost never prints. It goes in the request in chapter 9. 3. 3 **(V) and similar markers** A monitor value validated by a nurse is a number, not an assessment. Get the legend for every symbol. 4. 4 **Scale rows need the scale** A sedation score of 2 means nothing without the scale's anchors and the policy's action threshold. Same for pain, Braden, Morse and Glasgow Coma Scale rows. 5. 5 **Copied or carried-forward values** Most print views do not label them. Identical entries across shifts are a question for the metadata, not proof of copying. 6. 6 **Exception flags need their notes** Every asterisk or "see note" must link to a narrative. An exception flag with no note is itself a gap. 7. 7 **Who filed each value** Match user IDs to the staffing roster and the nurse you plan to depose. #### A reading procedure that holds up in a deposition 1. **Identify the unit, the date range and the policy family.** Med-surg, ICU and nursing home sheets run on different rules. 2. **Find the governing frequency for each row.** Policy, protocol, then physician orders; the tightest applies. Write it on your working copy: "sedation q2h on PCA per order 11/14 19:10". 3. **Lay out the expected columns.** List every time an assessment was due. This skeleton is how you tell a gap from a quiet stretch. 4. **Fill the skeleton from the flowsheet.** For each due time: charted, late, device only, or blank. Cite the page for every cell. 5. **Pull every exception note into the same timeline.** Narrative and event notes, the MAR, pump and rapid response records, call and paging logs. 6. **Mark trends inside the limits.** Values that stay WDL while moving in 1 direction (chapter 6). 7. **List the questions only the policy or metadata can answer.** That list becomes your discovery request. If you remember one thing Build the skeleton of due times first. A blank cell only means something when you can show an assessment was due at that time. Chapter 6 Everyone ### Trends inside the limits and copied values CBE grades each assessment on its own. A respiratory rate of 16, then 14, then 12 is WDL 3 times if the definition says 12 to 20. Oxygen saturation of 97%, 95%, 94%, 93% is WDL 4 times if the floor is 92%. No single cell triggers a note. The trend lives only in the numbers. That is the *Lama* theory in a modern chart: the numbers are there, but nobody wrote down the direction. Plaintiffs should chart the trend themselves, cell by cell, with page cites. Defendants should be ready to explain what the policy told the nurse to do about direction as opposed to thresholds. Many policies say nothing. #### Frequency itself is evidence Nurses change their behavior before they change their notes. A study at a large urban academic medical center tested that. 15,000 — acute care patients studied, plus 145 cardiac arrest patients, over 15 months 0.9 to 1.5 — more optional nursing comments in 48 hours for patients who died 6.1 to 10 — more vital signs documented in 48 hours for patients who died [Collins and colleagues (American Journal of Critical Care, 2013)](https://pubmed.ncbi.nlm.nih.gov/23817819/) found that optional comments and vital signs beyond what was required were associated with death and cardiac arrest, reflecting nurse concern. Extra vital signs, all WDL, with no exception note, suggest someone was worried and did not write down why. Neither pattern proves the standard of care by itself. #### Copy forward: when WDL is a keystroke The best-known measurement of copying comes from UCSF physician progress notes: **Where the text in an inpatient progress note came from** — n = 23,630 notes — Wang, Khanna and Najafi, JAMA Internal Medicine, 2017 Typical note460 clinicians 18% typed — 46% copied — 36% imported **Typed by hand — **Copied — **Imported by the EHR Less than a fifth of a typical note was typed fresh. The study covered physician and student notes, not nursing flowsheets, but on paper copied and fresh text look identical everywhere. In a flowsheet the equivalent is the "previous value" function, and a WDL entry has no wording to compare. If the same 9 rows read WDL every 4 hours for 3 days, the print cannot tell you whether a nurse assessed 18 times or pressed a key 18 times. Many EHRs store how a value was entered. Ask for it by name (chapter 9). #### Scale rows hide trends too The Braden scale for pressure injury risk has 6 subscales, with cumulative scores from 6 (highest risk) to 23 (lowest risk), per [Alderden and colleagues (2017)](https://pmc.ncbi.nlm.nih.gov/articles/PMC5587360/). A score drifting down 2 points a day may cross no threshold for days. The case often turns on the first date it crossed the facility's threshold, which the facility sets itself, and whether the ordered interventions followed. If you remember one thing CBE grades cells, not trends. Whoever charts the direction of the numbers controls the story of the gap. Chapter 7 Building ### Worked example: 12 hours of flowsheet and 1 exception note **Hypothetical.** The patient, hospital, policy, times and pages are invented to show the method. It is not a real case or a customer file. A 64-year-old patient returns to a surgical unit on 11/14/2025 after a total knee replacement with a hydromorphone patient-controlled analgesia (PCA) pump. Hospital policy NUR-DOC-114 (rev. 11/2024) requires respiratory status, oxygen saturation and a sedation score every 2 hours for the first 24 hours on PCA, and the 19:10 order set repeats it. RN-A covers 19:00 to 07:00. The flowsheet runs pages 212 to 215; the only narrative note is on page 219. **The night shift flowsheet, rows due every 2 hours** — hypothetical — Illustration Flowsheet, adult assessment, 11/14 to 11/15, hypothetical — 9 columns | Time | Respiratory | RR | SpO2 | Sedation | Pain | Filed | By | Page | | --- | --- | --- | --- | --- | --- | --- | --- | --- | | 19:00 | WDL | 16 | 97% 2L | 1 | 6 | 19:04 | RN-A | 212 | | 21:00 | WDL | 14 | 95% 2L | 2 | 4 | 21:02 | RN-A | 212 | | 23:00 | WDL | 12 | 94% 2L | 2 | 3 | 23:15 | RN-A | 213 | | 01:00 | WDL | 12 | 93% 2L | 2 | sleeping | 01:08 | RN-A | 213 | | 03:00 | (blank) | (blank) | (blank) | (blank) | (blank) | none | none | 214 | | 04:12 | (blank) | (blank) | 91% (V) | (blank) | (blank) | 04:12 | device | 214 | | 05:00 | (blank) | (blank) | (blank) | (blank) | (blank) | none | none | 214 | | 05:40 | * see note | 8 | 86% 2L | 4 | (blank) | 06:25 | RN-A | 215 | Gold rows: due assessments with nothing charted. Green row: the only exception, filed 45 minutes late. 4 WDL columns, 2 empty due times, 1 device number and 1 late exception. Every WDL on the page is defensible on its own. The page as a whole is not. #### The 1 narrative note Page 219, a nursing note labeled "late entry", entered 06:25 for 05:40: "Pt difficult to arouse on rounds, RR 8, SpO2 86% on 2L NC. PCA paused, HOB raised, sternal rub, RRT called 05:44. Naloxone given per RRT 05:46. Pt restless and snoring since approx 03:30, repositioned x2." The last sentence is the most important line in the chart for both sides. It puts the nurse at the bedside during the gap, and it records restlessness and snoring that a nurse expert may say called for a sedation assessment. None of it reached the flowsheet. #### The reconstruction **The same night, every source merged in time order** — hypothetical — Illustration; pages refer to the hypothetical production 1. 19:10 **PCA order with 2-hour monitoring** Order set repeats the policy frequency. Orders p. 205 2. 19:00 to 01:00 **4 on-time assessments, all WDL** RR falls 16 to 12; SpO2 97% to 93%; sedation 1 to 2. No cell crosses the defined limits. Flowsheet pp. 212 to 213 3. 00:30 to 02:30 **3 PCA demand doses delivered** The last delivered dose is at 02:28. PCA pump history p. 238 4. 03:00 **Assessment due, nothing charted** No respiratory, SpO2 or sedation entry. Flowsheet p. 214 5. ~03:30 **Nurse at bedside: restless, snoring** Known only from the 05:40 late entry. Repositioned. Nursing note p. 219 6. 04:12 **SpO2 91% flows from the monitor** Validated as a device value. No assessment row filled. Flowsheet p. 214 7. 05:00 **Assessment due, nothing charted** Second missed due time. Flowsheet p. 214 8. 05:40 **Difficult to arouse, RR 8, SpO2 86%** PCA paused. Charted at 06:25 as a late entry. Flowsheet p. 215; note p. 219 9. 05:44 **Rapid response called; naloxone 05:46** Patient responds. RRT record p. 241; MAR p. 230 The flowsheet shows 2 blanks. The merged timeline shows a downward trend, the last opioid dose, a bedside visit during the gap and a monitor value below 92% with no assessment. #### How each side reads it ##### Plaintiff reading The gap is the case - 2 assessments due under a binding policy (42 CFR 482.23(b)(6)); neither is charted. - Every WDL before the gap sits on a downward trend no one wrote down. - The nurse was at the bedside at 03:30 with snoring and restlessness; no sedation score followed. - The 04:12 SpO2 of 91% was validated with no assessment. - The only exception was charted 45 minutes late. ##### Defense reading The policy was followed where it counted - Every charted value met the rev. 11/2024 definitions, including the 91% at 04:12. - The nurse was present and observing during the gap; a missing entry is a documentation lapse, not a missing assessment. - Continuous pulse oximetry was running, and its alarm settings (if produced) show when it would have sounded. - The late entry is labeled, dated, timed and signed. - Rescue at 05:44 worked; causation for any lasting harm is a separate fight. Both readings need what neither has yet: NUR-DOC-114 as of 11/14/2025, the sedation scale's action threshold, the monitor's alarm limits and history, how the 04:12 value was validated, and whether any 01:00 values were copied forward. Chapter 9 turns that list into a request. If you remember one thing Merge every time-stamped source into 1 timeline before you argue about a blank. The note, the pump history and the monitor usually say more about the gap than the flowsheet does. Chapter 8 Building ### A blank field in a flowsheet: the decision path and the gap log Run every blank cell through the same questions in the same order, and log the answer. Each step can end the inquiry. 1 **Was an assessment of this row due at this time?** YesCite the source of the frequency, then go to 2. NoNot a gap. Log "not due". 2 **Do you have the defined normals and frequency policy in force on that date?** YesRead what the policy says a blank means. Go to 3. NoLog "gap, policy pending" and add the policy to your request list. 3 **Was the patient on the unit and available?** YesGo to 4. NoOff unit. The other department's record may hold the assessment. 4 **Does any other time-stamped source cover the window?** YesNote, MAR, pump history, monitor data, call log. Log what it shows and cite it. NoLog an unexplained gap. 5 **Does the covering source show an assessment, or only presence?** AssessmentA charting lapse with evidence the assessment happened. Weaker for the plaintiff. Presence onlyA device value, a repositioning, a med pass. Log "presence, no assessment", often the strongest entry. #### What a finished log looks like For the chapter 7 hypothetical, the sedation and respiratory log has 6 due times: Due time — Charted — Basis 19:00 — 19:04 — p. 212 21:00 — 21:02 — p. 212 23:00 — 23:15 — p. 213 01:00 — 01:08 — p. 213 03:00 — none — gap; presence at ~03:30, p. 219 05:00 — none — gap; device SpO2 04:12, p. 214 6 due — 4 charted — q2h per NUR-DOC-114, hypothetical ##### 1. Flowsheet gap log 1 line per due time, not per blank, with a page cite in every line. FLOWSHEET GAP LOG Matter: [CASE NAME] Patient: [INITIALS] Unit: [UNIT] Date range: [MM/DD/YYYY HH:MM] to [MM/DD/YYYY HH:MM] Reviewer: [NAME] Prepared: [DATE] ROW REVIEWED: [e.g. Sedation score] Frequency: [q2h] Source of frequency: [policy no./rev. date, protocol, or order + page] Defined normal for this row: [text, or "POLICY PENDING"] Policy meaning of a blank cell: [text, or "NOT STATED" / "PENDING"] Due time | Charted? | Filed time | Filed by | Value | Page | Other source in window (type, time, page) | Status [03:00] | [No] | [n/a] | [n/a] | [n/a] | [214]| [Note 05:40 describes 03:30 bedside, p. 219] | [Presence, no assessment] STATUS CODES Charted on time / Charted late (>[X] min) / Device value only / Gap, covered by other source / Presence, no assessment / Gap, unexplained / Not due / Off unit / Policy pending TRENDS INSIDE LIMITS (value, time, page for each point) [Row]: [16 @19:00 p.212] -> [14 @21:00 p.212] -> [12 @23:00 p.213] EXCEPTION NOTES Flag on flowsheet (time, page) | Linked note found? (page) | Note time vs filed time | Provider notified? (page) QUESTIONS FOR THE POLICY / METADATA / DEPOSITION 1. [e.g. How was the 04:12 SpO2 validated, and by whom?] If you remember one thing Log due times, not blanks. A jury understands "6 due, 4 charted, 1 bedside visit with no assessment"; "2 blanks" means nothing. Chapter 9 Building ### What to request: the CBE policy and defined normals in effect on the date A HIPAA access request or a records subpoena gets you the chart, not the policy. The right of access in [45 CFR 164.524](https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.524) reaches the patient's designated record set, and a nursing policy is not patient information. The policy, defined normals and flowsheet build come through party discovery, a subpoena, or a state pre-suit statute. Our guide on [how to get medical records for a lawsuit](https://medrecords.ai/guides/how-to-get-medical-records-for-a-lawsuit/) covers the chart side. Ask in the first request for production, not after the nurse's deposition. In federal court the other side has 30 days to respond under [FRCP 34(b)(2)(A)](https://www.law.cornell.edu/rules/frcp/rule_34). A request for "all policies and procedures" produces the current binder, which may be years newer than the care. Name the date. #### Why the version in effect is the whole request When a facility revises its defined normals, the same checkmark changes meaning. Here is a hypothetical revision of the chapter 7 respiratory row. **NUR-DOC-114 rev. 03/2021** — hypothetical Respiratory: within defined limits Respirations 12 to 20 per minute, regular, unlabored. Breath sounds clear bilaterally. SpO2 92% or above on room air. Frequency: every 4 hours and as needed. **NUR-DOC-114 rev. 11/2024** — hypothetical Respiratory: within defined limits Respirations 12 to 20 per minute, regular, unlabored. Breath sounds clear bilaterally. SpO2 90% or above, or at documented baseline, on room air or prescribed oxygen. Sedation score 1 or 2 for patients on opioid infusion or PCA. Frequency: every 2 hours for the first 24 hours on PCA or opioid infusion; otherwise every 4 hours. Under the 2021 text, the 04:12 saturation of 91% is an exception that called for a note, and with no 2-hour rule the 03:00 blank is not a gap. Under the 2024 text the 91% is WDL and the blank is a gap. Ask for every version from a year before the care to the present, with effective dates. ##### 2. Request for production: CBE policy and defined normals Adapt to your court's rules. Serve it with the first set. DEFINITIONS "Date of Care" means [MM/DD/YYYY] through [MM/DD/YYYY]. "Unit" means [UNIT NAME / NUMBER] and any unit where [PATIENT] received care during the Date of Care. "Flowsheet" means any structured nursing documentation template, grid or row-based form, paper or electronic, used on the Unit. REQUEST NO. [__] Every version of each policy, procedure or protocol governing nursing documentation on the Unit in effect from [DATE 12 MONTHS BEFORE] to the present, including any policy on charting by exception, flowsheet documentation or "within defined limits" (WDL) charting, with effective, revision and retirement dates. REQUEST NO. [__] The written definitions of "within defined limits," "within normal limits" or any equivalent entry for each assessment row in [PATIENT]'s Flowsheets, as in effect during the Date of Care, including EHR help text, hover text or row descriptions. REQUEST NO. [__] Documents sufficient to show the build of each Flowsheet row in [PATIENT]'s record during the Date of Care: allowed values, embedded definitions, defaults, copy-forward settings and device-integration settings. REQUEST NO. [__] Every policy, protocol or standing order in effect during the Date of Care setting the frequency of assessment for: vital signs; pain; sedation during opioid therapy [or PCA]; neuro checks; skin; fall risk; [OTHER ROWS]. REQUEST NO. [__] Any policy in effect during the Date of Care on the meaning of a blank Flowsheet cell, and on late entries, addenda and corrections. REQUEST NO. [__] The legend for every symbol or marker on the printed Flowsheets produced. REQUEST NO. [__] Training and competency records for [NURSE NAMES / ROLES] on the policies above, dated within [24] months before the Date of Care. REQUEST NO. [__] Monitor data, alarm settings and alarm history, and infusion or PCA pump history for [PATIENT] during the Date of Care, in native or exported form. REQUEST NO. [__] For each Flowsheet value from [TIME] to [TIME] on [DATE], data sufficient to show when it was entered, by which user, and whether it was typed, selected, copied forward or accepted from a device. The last request overlaps with EHR metadata discovery; see the [EHR audit trail in medical malpractice](https://medrecords.ai/guides/ehr-audit-trail-medical-malpractice/) guide, and [altered medical records](https://medrecords.ai/guides/altered-medical-records/) if an entry looks changed after the fact. #### Depose the facility on the policy Only the organization can tell you what its policy meant. Under [FRCP 30(b)(6)](https://www.law.cornell.edu/rules/frcp/rule_30) you "describe with reasonable particularity the matters for examination", and the designee must testify about information "known or reasonably available to the organization." Lock in definitions before the individual depositions. ##### 3. 30(b)(6) topics on flowsheet documentation Topic lists for an organizational deposition. State practice on corporate designee depositions varies. MATTERS FOR EXAMINATION, [FACILITY NAME] 1. The nursing documentation policies for [UNIT] during [DATE OF CARE], their approval, effective dates and revisions from [DATE] to present. 2. The meaning under those policies of "WDL", a checkmark, "see note", a blank cell, and each symbol in the Flowsheet legend. 3. The written normal-finding definition for [LIST ROWS], and where nurses could see it (policy manual, EHR help text, other). 4. Required assessment frequencies for [LIST ROWS] for a patient in [PATIENT]'s condition, and the source of each. 5. How the Flowsheet system records when a value was entered, by whom, and whether it was typed, selected, copied forward or accepted from a device. 6. Criteria for charting an exception and notifying a provider. 7. Training and competency validation for nurses assigned to [UNIT]. 8. Audits of Flowsheet documentation on [UNIT] in the 12 months before [DATE OF CARE], to the extent not privileged under [STATE STATUTE]. 9. The search for and production of documents responsive to [REQUEST NOS.]. #### Before you serve it - **Date of Care defined to the hour where it counts** *Shift changes and transfers split coverage.* - **Every unit the patient passed through named** *ED, PACU, ICU and med-surg run different flowsheets.* - **Version window runs from before the care to the present** *You want the change history too.* - **Embedded EHR definitions asked for by name** *Hover text is not in the binder.* - **Meaning of a blank cell requested separately** *Silence in the policy is also useful.* - **Frequency sources listed row by row** *Policy, protocol, order set, order.* - **Legend for print symbols requested** *Symbols differ across systems.* - **Device and pump data requested in native form** *They often sit outside the chart and rotate data.* - **Entry-method metadata requested for the key window only** *Narrow is harder to resist on proportionality.* - **Peer review and quality privilege checked for your state** *The policy itself is usually not protected.* **0** of 10 checked If you remember one thing Request the defined normals as of the date of care, in the first set. The current binder is the wrong document. Chapter 10 Deciding ### How CBE is defended, and how nurses get deposed on it The defense usually runs 3 arguments together: each WDL is an affirmative record of a normal assessment under a written definition; the nurses followed a routine practice of assessing on schedule (Rule 406 or a state equivalent); and CBE is an accepted method. The paper behind the grid decides which of them holds. #### Which facts make a CBE defense hold 1 — ##### Written, specific definitions in force that day Row-level definitions a nurse could apply. "Patient stable" undermines every mark on the grid. 2 — ##### Due times met Every required assessment charted at or near its due time. Most CBE defenses rise or fall here. 3 — ##### Exceptions charted and escalated Each abnormal finding has a linked note and a documented provider notification where the policy required one. 4 — ##### Independent time-stamped data Monitor data, alarm logs, pump history and MAR entries that fill a gap without relying on memory. 5 — ##### Training and competency records Proof the nurses were taught the definitions before the date of care. 6 — ##### Testimony about routine practice Weakest alone. A nurse describing her habit invites the question of why the habit left no mark at 03:00. This order is our view of how juries weigh the evidence, and it tracks *Lama*. Defense counsel should audit the chart against it before deciding whether to defend the documentation or concede it and fight causation. #### Where plaintiffs attack - **The definition.** Vague, missing, not in force that day, or never shown to the nurse. - **The frequency.** Due times with nothing charted, or batch-charted at shift end. - **The trend.** WDL values moving in 1 direction with no note. - **The exception.** Late, unescalated, or contradicted by other sources. - **The keystroke.** Identical WDL entries across shifts, filed seconds apart. ##### 4. Nurse deposition outline: charting by exception For the bedside nurse, after you have the policy and the gap log. State rules on objections vary. A. BACKGROUND AND TRAINING 1. When were you trained on [FACILITY]'s flowsheet documentation? By whom? 2. Were you shown the written definitions of WDL for each row? Where were they kept? (policy manual, EHR help text, unit binder) 3. When did you last read them before [DATE OF CARE]? B. THE DEFINITIONS (show Exhibit [__], policy rev. [DATE]) 4. What did WDL mean for the [ROW] row on [DATE]? Read it into the record. 5. What does a blank cell mean under this policy? 6. What does [SYMBOL, e.g. (V)] mean on the printed flowsheet? C. FREQUENCY 7. How often were you required to assess [ROW] for this patient? Source? 8. Show Exhibit [__] (gap log). At [03:00], what did you assess? Where is it recorded? 9. Is there any record of an assessment at [03:00] other than your memory? D. THE ENTRIES 10. For the [01:00] column: did you assess each row, or carry values forward? 11. How does the "previous value" function work on your unit? 12. The [04:12] SpO2 value: how was it validated? Did you see the patient? 13. When did you chart the [05:40] entry? Why was it a late entry? E. THE NOTE (Exhibit [__], p. [219]) 14. You wrote "restless and snoring since approx 03:30." What did you see? 15. Did you assess sedation or respirations at that time? Where is it? 16. Did you notify a provider before [05:40]? Where is that recorded? F. MEMORY VS HABIT 17. Do you remember this patient, or are you describing your usual practice? 18. How many patients were you assigned that night? (staffing record) If you remember one thing A CBE defense is only as strong as the due times it met. If the frequency did not hold, the defense usually moves to causation. Chapter 11 Everyone ### AI medical record review on flowsheets: where it helps and where it fails A 5-day admission can produce hundreds of pages of grids, with the deciding facts scattered across them: a blank due time on page 214, the pump history on page 238, 1 sentence in a late entry on page 219. Legal AI tools are good at the finding half of that work. Do not trust them with the judging half. #### What a large language model does well here - **Putting every entry in time order.** An AI medical chronology that merges flowsheet values, notes, the MAR and device records, each line cited to its source page, builds the chapter 7 timeline in minutes instead of days. - **Finding the exception notes.** Clinical natural language processing picks out "late entry", "RRT called" and "provider notified" across thousands of pages. - **Surfacing date and time gaps.** Stretches with no entries, late-filed entries, notes that contradict the grid. - **Answering narrow questions with citations.** "List every sedation score from 19:00 to 07:00 with page numbers" is a good prompt. "Was the nurse negligent?" is not. - **Expanding abbreviations.** HOB, NC, RRT, POSS and unit shorthand; see [medical abbreviations for legal professionals](https://medrecords.ai/guides/medical-abbreviations-for-legal-professionals/). #### Where it fails - **OCR on grids.** Optical character recognition can shift a value into the wrong column on a dense or faxed flowsheet, and the wrong column is the wrong time. - **Blank versus unreadable.** A faint cell read as empty creates a gap; an empty cell filled from its neighbor erases one. Low-confidence pages must go to a person. - **Handwritten notes and paper downtime forms.** Handwriting recognition still needs someone who knows the unit's shorthand. - **What the print does not carry.** Hover-text definitions, copy-forward metadata, device validation. No tool reading a PDF can see them. - **Hallucination.** Ask a general chatbot what WDL means in this chart and generative AI will offer a textbook definition as if it were the facility's. - **Judgment.** Breach, credibility of habit testimony, whether a trend called for escalation: expert and counsel questions. Reviewer alone Build the due-time skeleton — By hand from the policy Merge flowsheet, notes, MAR, pump — A spreadsheet, over days Spot a 1-line admission in a late entry — Only if you read that page closely Decide what a gap means — Nurse expert and counsel With AI, human in the loop Build the due-time skeleton — Still by hand from the policy Merge flowsheet, notes, MAR, pump — Drafted chronology, every line cited to its page, then checked Spot a 1-line admission in a late entry — Surfaced in the timeline at its stated time Decide what a gap means — Still the nurse expert and counsel #### Why page-level citations decide whether the output is usable In a charting-by-exception file, the question is always what the flowsheet shows on a given shift. Grounded, page-level citations send the nurse expert straight to that flowsheet, and a human-in-the-loop check of every row decides what the blank boxes mean. In *Mata v. Avianca, Inc.*, 678 F. Supp. 3d 443 (S.D.N.Y. 2023), lawyers were sanctioned under Rule 11 for filing case citations a chatbot had invented. The same duty to verify applies to a chronology an expert relies on or a gap log attached to a motion. Ambient AI scribes now draft some clinical notes from recorded conversation, and an accepted draft can read as complete while describing an assessment in general terms. Ask in discovery whether any AI drafting tool was used on the unit, and check a scribe-drafted note's times against the grid. #### Choosing legal AI tools for flowsheet work The market for AI document review, technology assisted review and agentic AI tools for lawyers is crowded. For CBE work, rank requirements in this order: 1 — ##### A citation on every line Every value, time and quote opens the source page. No citation, no use. 2 — ##### HIPAA compliant AI with a signed BAA A business associate agreement before any record is uploaded. Consumer chatbots without one are out. 3 — ##### SOC 2 and no training on your data An independent security report and a written no-training commitment. 4 — ##### Low-confidence pages flagged Grids, faxes and handwriting the OCR was unsure of, marked for a person, never silently guessed. 5 — ##### Times kept as written Stated time and filed time both preserved, never averaged or rounded into 1. 6 — ##### An audit trail of AI use A log of who uploaded, viewed and edited what, for chain-of-custody questions about your work product. See also [is AI accurate enough for court](https://medrecords.ai/guides/is-ai-accurate-enough-for-court/), [HIPAA-compliant AI medical record review](https://medrecords.ai/guides/hipaa-compliant-ai-medical-record-review/) and the [AI-native legal nurse consultant](https://medrecords.ai/guides/ai-native-legal-nurse-consultant/) manual. If you remember one thing Let AI build and cite the timeline. Build the due-time skeleton from the policy yourself, and let people decide what each gap means. Chapter 12 Publisher ### What Medrecords AI does with a flowsheet chart, and what it does not Medrecords AI is medical record review software. You upload the records; it drafts a cited chronology, summaries and flags, every line linked to its source page. On a flowsheet chart: - **A [cited medical chronology](https://medrecords.ai/product/chronology/) ** of flowsheet values, notes, medication and rapid response records in time order, with [a citation on every line](https://medrecords.ai/product/citations/). - **Date and time gaps flagged** : stretches with no entries, and records that should exist and were not produced, through [missing records identification](https://medrecords.ai/product/missing-records-identification/), each flag cited to its evidence. - **Inconsistencies flagged** : a note that contradicts the grid, a late-filed entry, an entry dated outside the admission. - **Low-confidence pages marked** for a person, including dense grids, faxes and handwriting, through [OCR](https://medrecords.ai/product/ocr/) and [handwritten record extraction](https://medrecords.ai/product/handwritten-medical-record-extraction/). - **Questions answered with citations** through [Q&A](https://medrecords.ai/product/qa/): "every sedation score on 11/14 with pages". - **New productions compared to the file you have** through [supplemental record review](https://medrecords.ai/product/supplemental-record-review/). Flags are signals, not verdicts. A time gap may be a missed assessment, a patient off the unit or a page missing from the production. A human decides which. What it does not do: it does not know a unit's required assessment frequency or read the policy against the chart; the due-time skeleton is your step. It does not read EHR exports or entry-method metadata, so it cannot tell a copied WDL from a typed one. It does not decide breach, score case merit, give legal advice or retrieve records from providers. It works on the files you upload, under SOC 2 and HIPAA with a signed BAA (see [security](https://medrecords.ai/security/) and [HIPAA](https://medrecords.ai/hipaa/) ). Self-Service bills 10 cents a deduplicated page, down to 5 cents at volume, duplicates free; Enterprise On-Prem is an annual license. See how this applies to [hospital nursing negligence](https://medrecords.ai/solutions/hospital-nursing-negligence-record-review/), [nursing home neglect](https://medrecords.ai/solutions/nursing-home-neglect-record-review/) and [legal nurse consultant](https://medrecords.ai/solutions/legal-nurse-consultants/) work. The offer #### See every flowsheet entry in time order, cited to its page. Book a demo on a nursing chart with gaps you need to explain, then run your first case free on us. Every line comes back cited to its source page. You review, you revise, you sign. [Book a demo](https://medrecords.ai/demo/) [See the cited chronology](https://medrecords.ai/product/chronology/) Scheduling only. No records move from a public page. Chapter 13 Everyone ### Frequently asked questions What is charting by exception in nursing?A method in which the facility writes down what a normal finding is for each assessment area, and nurses chart in detail only findings that depart from it. The assessments still happen at the required frequency; only the documentation of normal findings is shortened. What does WDL mean in a nursing chart?Within defined limits: the finding met the facility's written definition for that row. You need the definition in force on the date of care, which may sit in EHR help text that never prints. Does "not documented, not done" apply to charting by exception?It is a nursing maxim, not a rule of law. A blank cell at a time an assessment was due is still a gap under CBE. Federal Rule 803(7) lets a party use an absent entry if that kind of record was regularly kept. State rules vary. Is charting by exception negligent?No court we found has held the method negligent in itself. *Lama v. Borras* (1st Cir. 1994) affirmed a verdict where the hospital conceded its CBE practice broke a Puerto Rico regulation, and the jury linked the missing notes to a delayed diagnosis. What should I request to understand a CBE flowsheet?Every version of the documentation policy from before the care to the present, the defined normals including EHR help text, frequency policies and orders, the policy on blanks and late entries, the symbol legend, training records, and monitor and pump data. Can a nurse testify to her routine practice to fill a blank?Often, yes, under Federal Rule of Evidence 406 or a state equivalent. The court decides whether the testimony qualifies as habit, and a jury may give it little weight against a missing entry. Can AI read a nursing flowsheet?AI tools can extract values, merge them with notes and medication records into a cited timeline, and flag time gaps. They struggle with dense grids after OCR, faxed cells and handwriting, and cannot see definitions or metadata that never printed. A person checks every cited value. Can software tell whether a blank cell means the assessment was not done?No. It can show that a cell is empty and nothing else in the file covers the window. Whether the assessment was due and happened depends on policy, other records and testimony. Is it HIPAA compliant to upload medical records to AI?It can be, with a vendor that signs a business associate agreement, holds a SOC 2 report, and commits in writing not to train on your data. A consumer chatbot without a BAA is a different matter. Can ChatGPT summarize a flowsheet for a lawsuit?It can produce a fluent summary, but without page-level citations you cannot check it, and it may fill gaps with plausible values. Lawyers have been sanctioned under Rule 11 for filing invented AI citations (*Mata v. Avianca*, S.D.N.Y. 2023). Verify every line before you rely on it. Chapter 14 Everyone ### Sources and method Rules, regulations and the *Lama* opinion were read in full text from primary sources in September 2026; quoted text is verbatim. Study figures come from the published papers. The flowsheet, policy, patient, times and pages in chapters 5 and 7 to 10 are hypothetical. Product facts come from this site's product pages. Nothing here is legal or medical advice. - [*Lama v. Borras*, 16 F.3d 473 (1st Cir. 1994)](https://law.resource.org/pub/us/case/reporter/F3/016/16.F3d.473.93-1072.93-1071.html), decided February 25, 1994: facts, verdict, footnotes 3, 10 and 11, causation holding. - [Tammelleo, "Court holds 'charting by exception' policy negligent"](https://pubmed.ncbi.nlm.nih.gov/7517052/), Regan Report on Nursing Law, 1994. - [Federal Rule of Evidence 803(6) and (7)](https://www.law.cornell.edu/rules/fre/rule_803) and [Rule 406](https://www.law.cornell.edu/rules/fre/rule_406). - [Federal Rule of Civil Procedure 34(b)(2)(A)](https://www.law.cornell.edu/rules/frcp/rule_34) and [Rule 30(b)(6)](https://www.law.cornell.edu/rules/frcp/rule_30). - [42 CFR 482.24(c)(1)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.24) and [42 CFR 482.23(b)(4) and (b)(6)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.23), hospital Conditions of Participation. - [42 CFR 483.20(b)(2), (c), (d), (g) and (j)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.20), nursing home resident assessment. - [45 CFR 164.524](https://www.ecfr.gov/current/title-45/subtitle-A/subchapter-C/part-164/subpart-E/section-164.524), HIPAA right of access. - [Murphy, Beglinger and Johnson, "Charting by exception: meeting the challenge of cost containment"](https://pubmed.ncbi.nlm.nih.gov/3257552/), Nursing Management 19(2), 1988. - [Collins et al., "Relationship between nursing documentation and patients' mortality"](https://pubmed.ncbi.nlm.nih.gov/23817819/), American Journal of Critical Care 22(4), 2013: 15,000 acute care patients, 145 cardiac arrest patients. - [Wang, Khanna and Najafi, "Characterizing the Source of Text in Electronic Health Record Progress Notes"](https://pmc.ncbi.nlm.nih.gov/articles/PMC5818790/), JAMA Internal Medicine 177(8), 2017: 23,630 notes, 18% typed, 46% copied, 36% imported. - [Alderden et al., "Midrange Braden Subscale Scores Are Associated With Increased Risk for Pressure Injury Development Among Critical Care Patients"](https://pmc.ncbi.nlm.nih.gov/articles/PMC5587360/), J Wound Ostomy Continence Nurs, 2017: Braden range 6 to 23. - [Nurses Service Organization, "Charting by exception: the legal risks"](https://www.nso.com/Learning/Artifacts/Articles/Charting-by-exception-the-legal-risks): insurer guidance to nurses on CBE documentation. - *Mata v. Avianca, Inc.*, 678 F. Supp. 3d 443 (S.D.N.Y. 2023): Rule 11 sanctions for filing fabricated AI-generated case citations. 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