Just Curious...

  1. What is your protocol for "Late Entry?" How does your facility define "Late Entry?" In nursing school, we are taught to chart right as the events are occurring, and if not, to put "Late Entry." With today's hectic floors, is anyone able to chart right as the events are occurring? I remember LOTS of shifts in which I made my first note 12 hours later at the end of my shift--so busy, I had NO TIME to chart, much less eat, drink, or pee. Do you make quick notes to yourself and then chart later? If so, are your entries then dubbed "Late Entries?"
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  2. 7 Comments

  3. by   gwenith
    From what I understand haveing spoken to nurse solicitors it does not really matter WHEN an entry was made it is still valisd in court it is just that those amde closest to the time are most valid. She recommended that if there was something you forgot to chart to write it time and date it as soon as you got home. She said for the purposes of the court it did not really matter if you wrote that note on letterhead or toilet paper :chuckle: It would still be valid.
  4. by   rachel h
    I just jot down things on my worksheet that I need to include in my note, which I almost always write at the end of my shift, there is NEVER time to chart as events occur, unfortunately. I don't enter my notes as a 'late entry'- I've never seen any nurse's notes labeled as such in any of my patient's charts either. Even if there were time to chart as events happened, I think I would end up with about 30 notes on each patient by the end of the night. Much more convenient just to write one.
  5. by   jemb
    The only times I have ever labelled anything in my charting a "late entry" were when I forgot to chart something in sequence, whether it was for the same shift or for a prior day
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    For example if I had forgotten to chart that I had restarted Mrs. Xyz's IV the prior day, my charting would read something like:



    [FONT=century gothic]Late entry: Date and time of event . Pt. c/o pain at IV site rh. Site /s redness or swelling. Catheter removed intact and IV restarted to LFA /c #22 angio.
    Then I would sign it and date it with the date and time of charting.
  6. by   meownsmile
    We dont write late entry. Our policy is to circle the time of the entry if it is out of sequence. If it is on another day it is appropriate to go back to that days flow sheet, document it and circle the entry time.
  7. by   Agnus
    A late entry is technically something charted out of time sequence. As jemb, has stated.
    So I charted at 0700 I did something at 0800 I did something esles at 0900 the patient did some thing. Then I remember that at 0830 something happened and I go back and put. "late entry 0830".....

    It doesn't matter that you chart at the end of the day. As long as it gets charted. Charting as things happen is ideal but rarely possible. The idea of charting as you go is so you don't forget something. But I have even had to chart a 'late entry' charting as I went.
  8. by   sassynurse78
    I only use "late enrty" if I have already charted something for 8 and then realized I needed to chart something at 7. Or maybe I got home and remebered something and had to put it in as a late entry the next day. I chart almost everything at the end of my shift, or lately after But I keep a cheatsheet in my pocket at all times and write down anything I need to chart when I can chart it and mark things off as I am done.
  9. by   purplemania
    In our facility a Late Entry is defined as one made within 24 hours of when it should have been documented. This is done by dating, putting current time and the remark "Late Entry" then proceeding (ie. 5/19/03 0800. Late Entry: At 0300 ---). An Addendum is an entry made >24 hrs. later. It has to be approved by the nurse manager and risk mgmt.. Addendums tend to look like coverups.

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