Violation of the Nurse Practice Act?

Editorial Team / Admin · Dec 29, 2006

Hello, PrisonrNurs,

No, late entries are not a violation of the NPA.

Agnus · Dec 29, 2006

Late charting is not a violation of any NPA. However, It concenrs me that you talk about major charting like assessments that are not entered until a week or month later.

If I were a juror I would wonder just how accurate that charting is. I can not remember patients that long let alone what thier assessment was.

NPA does require accurate charting.

wincha · Dec 29, 2006

Hello everyone,
In our facility we do a lot of QA's on our charts. Anytime there is a discrepency, we have to go in and correct them. Most are very minor...a discrepency when a patient leaves the ER, but some are more important, like not charting the initial assessment or the discharge information. Some can be a week old, but some can be from months ago, depending on when the QA is done.
My question is this: Does a late entry consititue a violation of the Nurse Practice Act? A review of the North Dakota NPA does not clearly outline this, nor does our facility's policy and procedure. What do you think?

late entry is one thing, changing or adding information in the chart is illegal.

wincha · Dec 29, 2006

Late charting is not a violation of any NPA. However, It concenrs me that you talk about major charting like assessments that are not entered until a week or month later.
If I were a juror I would wonder just how accurate that charting is. I can not remember patients that long let alone what thier assessment was.
NPA does require accurate charting.

The hospital would have major problems in a lawsuit if you are adding an initial assessment a week later. If you have a late entry later in the day thats one thing to chart it as a late entry. Even so if there was a law suit it most likely would get thrown out as it was not charted at that time and could have been made up.

Home Health Columnist / Guide · Dec 30, 2006

Hello everyone,
In our facility we do a lot of QA's on our charts. Anytime there is a discrepency, we have to go in and correct them. Most are very minor...a discrepency when a patient leaves the ER, but some are more important, like not charting the initial assessment or the discharge information. Some can be a week old, but some can be from months ago, depending on when the QA is done.
My question is this: Does a late entry consititue a violation of the Nurse Practice Act? A review of the North Dakota NPA does not clearly outline this, nor does our facility's policy and procedure. What do you think?

Hello, PrisonrNurs,
No, late entries are not a violation of the NPA.

Within one month is usual standard for chart corrects in most inpatient facilities.....trying to get some docs is like pulling teeth.

Some times takes homecare 6-9 months to hunt down docs for missing signatures. We wont ADD any info to a homecare chart after 45 days unless MIA signature.

Loved year Medical Director suspended Chief surgeon on 12/31 for being 3 months late with charts.....

lauralassie · Dec 30, 2006

As long as the date the entry was made, your signature is clear and the documentation is noted to be "Late entry" you should be OK. But be sure that your documentation is accurate to the evets, don't fill in a blank for administration, it will be your reputation on the line in the court room. I am confident the hospital will not stand beside you and say, this nurse felt obligated to make this entry because we brow beat our employees to make records look good for JACHO. :cool: