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Discussion

Charting Help!!!

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

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    • Featured Replies

    Good question...

    NomadNurse

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    • Experts

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

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    • Author

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

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

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    • Author
    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!

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    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.

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    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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