This is a discussion on nurse documentation in Patient Education, part of General Nursing ... I'm a nurse in New Jersey and have been having this running discussion that nurses are allowed to...
I'm a nurse in New Jersey and have been having this running discussion that nurses are allowed to make an addendum up to 24 hrs. I say we can and several other nurses on staff agree but there are a few that say that once your done and your shift is over there's no going back. If an addendum is allowed where does it say that we can do this. Is this NJ nurse policy?
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May 2, '10 by AggieNurse99
You can almost always make a "Late Entry" as long as it is documented as such. i.e. 5/2/2010 2103 Late Entry: 1700 bedside paracentesis by Dr. Blank. 1300 ml clear, straw colored fluid aspirated. Sample sent to lab. Covered with bandaid. Pt tolerated without complaint. My hospital 'closes' the electronic chart 72 hours after discharge.
Last edit by AggieNurse99 on May 2, '10
: Reason: Continued