documentation

[mstere]

Can someone tell me how long a nurse has to change documentation? In meditech. For example. I was told that I documented in falsification. Which I can say was NOT intended. I was NOT given an opportunity to make changes and...it did not harm a patient. Think I will lose my job.

[NicuGal, MSN, RN]

You can't change what is charted. It is a permanent part of the chart. The only thing you can do is say it is a mistaken entry and rechart but it will always be present in the chart.

[napalmer927]

I always heard that you had 24 hours to change something, but NicuGal is right that the original will always be there.

[RainMom]

We use meditech & I believe entries can be changed up to 48 hrs. That may be something that can be customized to facility preference though.

What kind of entry mistake was it? Everyone I know has made mistakes, some that were found immediately & some found hrs later. Often it is charting on the wrong pt or transposing digits when entering vs. It's fixed by using "undo" to remove it completely or changing the original entry but like mentioned above, will always show that the edit was made.

[NicuGal, MSN, RN]

Anything that is entered into an EMR is there forever. There is no erasing it. It will be a mistaken entry. You can go back anytime and alter anything, which I wouldn't advise, but your footprint is always there. If it is something that needs amended do it as a late entry.

[Lev, MSN, RN, NP]

Sometimes I chart so fast, that I mistakenly check the wrong boxes. Today I documented friction rub instead of inspiratory wheeze (They were right next to each other).

[Nurse Kyles, BSN, RN]

We can go in and edit charting in meditech for 4 days. I suspect that the length of time can be customized by the facility.

[Davey Do]

An addendum to charting, additional information, or an alternate pespective, is an acceptable method of charting to bring a status up to date.

I note "acceptable method" because I've never been called out on it.

I'm comfortable with this method because it's what happens in the real world. We cannot be expected to cover all the bases all the time in an imperfect world.

In addition, I do not use words like "error" or "wrong" or "mistaken" and merely note an objective description of the facts.

[turnforthenurse, MSN, NP]

We are able to "modify" things that we chart or unchart them if say they were entered at the incorrect time or entered on the wrong patient (I'm sure many of us have done this, I know I have) but the original charting will still be there in the chart. Everything you chart becomes a permanent part of the patient's EMR and there's no way of erasing it.

[HouTx, BSN, MSN, EdD]

Refer to your organization's P&P for all the documentation 'rules' you need to follow.

[j0yegan]

If you are unable to change anything, just make a nurse note / SOAP note / narrative note.