Charting Help!!!

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Specializes in PN NURSING SCHOOL.

Hello Nurses,

Hope you can help me with this. I had a situation where I worked one of my PRN jobs about a month ago. And I had lots of charting to do. A couple of weeks later I realized that when I charted on one of my residents I put continent of bowel and bladder but in reality has a colostomy. What do I do to fix the situation? It's almost been a month I last worked there! Should I do an addendum? I know I do a lot of overthinking but I don't want to lose my license

Good question...

NomadNurse

Call the facility and speak to the supervisor or the DON and ask them what they want you to do.

Specializes in PN NURSING SCHOOL.

Thanks a bunch! I thought it was too late to do anything at all. Being it was skilled charting. I'm totally freakin out!

Specializes in Gerontology, Med surg, Home Health.

You're not going to lose your license because of a charting error...and, since the person has a colostomy, technically they are continent.

Specializes in PN NURSING SCHOOL.
You're not going to lose your license because of a charting error...and, since the person has a colostomy, technically they are continent.

Thanks CapeCodMermaid. I can finally stop worrying!

Call and ask the DON what they want you to do. They will probably want you to come in and chart a late note as an addendum. While this is an oops, it won't cause problems with your license.

Specializes in Geriatrics, Dialysis.

Don't sweat it, it happens. You should be able to enter an addendum to correct your error. Chart a late entry note acknowledging the initial error and indicating what the correct charting should have been. Heck I once charted a bed bound end stage MS pt with a g-tube and a trach as alert, oriented and independent with all ADL's including ambulation and feeding...boy did I get some ribbing for that! Just plain charted on the wrong resident, when you have 28 of them that is surprisingly easy to do.

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