correcting documentation after several days

[sassyann85]

Just wondered how everyone would handle this--

This happened during my shift Friday, but I didn't realize it til Saturday night (and I was off work Saturday and am off today).

I realized I think in the electronic MAR (we use scanners to scan meds as well) I scanned a PRN Ativan I gave a patient, signed it off, then there was a crisis on the unit in the middle of all this so when I got back to the med room, I forgot I had already signed the dose off so I "rescanned" the Ativan and documented it again for that patient. Basically, I documented the same dose of Ativan twice. So now, when I work tomorrow which is several days after this occurance, do I go back and correct the emar and time the correction for Monday. Is this ok? Or is it too late to correct? The record in the pyxsis would back up the fact I only removed one dose for the patient.

[applewhitern, BSN, RN]

Shouldn't you be asking your manager or supervisor this? At my hospital, we would indeed make a correction, but specifically how that is done may vary from facility to facility.

[psu_213, BSN, RN]

Shouldn't you be asking your manager or supervisor this? At my hospital, we would indeed make a correction, but specifically how that is done may vary from facility to facility.

Exactly…does your facility actually want you to alter the MAR? Are you even able to? Or does the facility want you to write a late entry nurse's note? You should alter the chart so the information is correct. The question is, what is the facility policy on what should be corrected?

[ixchel]

I believe at my facility, we'd do an incident report for that. Your system really should have a pop up or something that prevents you from signing off a med when it's too soon to give. It shouldn't have let you do that. I wouldn't change your documentation days later because it will look suspicious. At the least, ask your manager what they advise.

[firstinfamily, RN]

Exactly, you need to ask your manager what the policy is. Electronic MARs will reflect what you documented, how to correct this days later may be difficult. Usually there is a 24 hour limit on correcting errors however, every facility is different.