Documentatio question

[Celia M]

Is it ever OK to document on a patient chart ahead of time, eg make an entry for 10 00 at 07 00. Thanks

[krob0729]

EastTxLVN: You say you take notes all noc long then rewrite them. I don't say this is wrong, or illegal, but I have a word of caution for you. One "sign" of medical record tampering can be how "neat" a record looks. Let me explain. If you were to sit down at the end of shift and could write your notes without interruption they would look neater and more consistent than if you wrote them throughout the noc, some "on the fly" because you were in a hurry. Do you follow me? If that record were pulled someone would most likely ask how you had been able to write each individual entry almost consistently. Just a comment on my part. MLF/RN nurse

I see what your saying and agree, maybe I should clarify myself. I don't write ALL my notes at the end of the night, I'll make a quick note of the time and what was done if something comes up unexpected and I can't get to the chart right then and there to chart it. As soon as I have 5 min to breathe I'll go grab the chart and jot it down real quick. I just don't want to miss the time I did something and have to estimate.