Published Sep 28, 2005
night owl
1,134 Posts
Out of all the paperwork that has to be done, treatments, meds and what not, do you ever start thinking during the drive home and find out you forgot to do something? Ok, I admit, sometimes I do :imbar and I don't make a habit of it. If it's really important, I'll call when I get home and let them know. If it's a treatment, they'll know because my initials won't be on the dsg, but what would happen if you forgot to write a note on something, but you reported it in report and wrote it in the report book. Can you make a late entry in the computer/chart and would this be illegal?
Don't worry, I won't tell. :chuckle
Antikigirl, ASN, RN
2,595 Posts
LOL, oh yesss, that black cloud feeling that something has been left undone! Oh I get that all the time, most often it was something I just wanted to add to report, or an initial I didn't sign...nothing too serious. I also call and talk to the shift nurse if I feel it can not wait till my next day!
I think everyone no matter what profession has that happen! Kinda like everytime you walk out the door for work and think "did I forget something???".
I just make it a habit to take a break before I leave for home, like 5 minutes or so to go over my notes and see if I forgot something. I also make a check list for each day I work with every bit of documentation needed, and check them off as I go. Man I can write those little check boxes and items fast now...from the moment I am called...those boxes are there with initials representing charting I need to do...or I will forget...happens when you get 5 or more calls in tandem!
I call that notebook my brain..and believe me, if I loose it...I am clueless..LOL!!!!!!!
donmomofnine
356 Posts
Yes, you can make a late entry. You put the date and time you are writing and then write "late entry for _______"(date and time of occurrence).
I always forget stuff. Usually I remember the big stuff and forget little things!:)
Thank you donmomofnine. I've made late entries in the past, but no one could tell me if it was ok to do. Just covering my butt alittle later. :)
I know we're not all perfect and we're bound to forget something sometimes. :uhoh21:
Nascar nurse, ASN, RN
2,218 Posts
ANYONE who says they NEVER forgets to do something is a BIG FAT LIAR! This is just human nature. Do the best you can, admit your mistakes and live and learn from it. I wouldn't want a cold hard robot for a nurse - I'll take a real human being, although imperfect anyday of the year. Also we do late entries exactly like the above poster said to do them and I looks like we are several states away. I guess you should be safe to follow the same guideline.
CoffeeRTC, BSN, RN
3,734 Posts
OMG....all the time! Well not all the time, but we all have. Sometimes I will think of something on my way home and call. As far as charting...yep you can make a late entry, just like don said.
People hate me because I love to utilize the report sheet. I take it with me on med pass and write on it as I go, then I will chart using it for notes.