late entry

Midwest4me · Feb 2, 2009

I have a question: Is it ok to write "late entry" in the nurses notes?

Of course it is. Let's suppose that the event happened on 1/31/09. You didn't document it that day. You remember to do it on 2/2/09. You write in the progress notes: 2/2/09. Late entry for 1/31/09: and proceed to document the event. That's how we do it in our state, anyway.

achot chavi · Feb 2, 2009

Agreed- better late than never!!

classicdame, MSN, EdD · Feb 2, 2009

Agreed, but there may be rules or even state laws governing how it is done. In my facility, under 24 hours the chart MIGHT be still on the floor and accessible to the nurse. Once it leaves the floor, or once 24 hours has transpired, the nurse must get permission from Risk Management. I think the idea is that lawyers get suspicious if you have a day or two to think about what you WISHED you had written. Best to ask your supervisor or check the policies for your facility. Or both.

debRN0417 · Feb 2, 2009

I agree..better late than not at all....

caliotter3 · Feb 3, 2009

Done quite often. However, you should attempt to be careful about doing it on a consistent basis, because a pattern of late entries is a bad indication to management that you are not careful about managing your time wisely and are not careful about charting in general. Try to make a habit of completing your charting on a shift to shift basis so you can avoid late entries except for that once in awhile one that gets past you.

achot chavi · Feb 3, 2009

Agreed, but there may be rules or even state laws governing how it is done. In my facility, under 24 hours the chart MIGHT be still on the floor and accessible to the nurse. Once it leaves the floor, or once 24 hours has transpired, the nurse must get permission from Risk Management. I think the idea is that lawyers get suspicious if you have a day or two to think about what you WISHED you had written. Best to ask your supervisor or check the policies for your facility. Or both.

Not a problem- just explain to Risk Management what you want to write , if its kosher- it shouldn't be a problem, if they refuse, just write a memo to your DON. The purpose is to write on something you forgot or didn't have time for or maybe the chart was unavailable when you wanted to write. You shouldn't write in order to change info or misconstrue something or to even a score with another nurse or doctor. Make sure you are on the up and up and admit you are human. This shouldn't be a daily occurrence- happened to me twice in my career.

mlolsonny · Feb 7, 2009

Our computerized software even labels notes as late-entry if the date is changed from the current date. It puts them in the correct order with the date that you've back-dated to with the note "Late-entry made on x/x/xx at xx:xx."