Documentation Error?

[nursing_newbie]

Hey all,

On new grad orientation and realized two days after a shift, I think I did not submit care plan documentation/progress notes on a pt. I'm feeling terrible about this. How bad is this? Should I reach out to my ANM? Thanks in advance.

[Sour Lemon]

1 minute ago, nursing_newbie said:

Hey all,

On new grad orientation and realized two days after a shift, I think I did not submit care plan documentation/progress notes on a pt. I'm feeling terrible about this. How bad is this? Should I reach out to my ANM? Thanks in advance.

I can't imagine that's an interruption they'd appreciate, although I don't know your exact circumstances. I only call about things that will have an immediate negative effect on the patient's care if they are not caught/corrected. And in those cases, I call the nurse currently assigned to the patient.

[nursing_newbie]

@Sour Lemon Thanks for the input! There was nothing urgent that happened over shift, but being new I just feel terrible about forgetting anything. A mistake I don't see myself making again in the future.

[CharleeFoxtrot, BSN, RN]

8 minutes ago, nursing_newbie said:

@Sour Lemon Thanks for the input! There was nothing urgent that happened over shift, but being new I just feel terrible about forgetting anything. A mistake I don't see myself making again in the future.

and that's the best kind of mistake ? and an even better attitude!

[FurBabyMom, MSN, RN]

I mean - it might be a good idea to seek clarification as to what circumstances warrant correcting a chart after the fact. In the scheme of things, one entry in a care plan probably isn't that big of a deal...whereas a missed assessment might be. Your ANM or current/former preceptor can probably provide some insight into what the unit "standard" or service line standard may be.