Documenting

[izzy_2468]

I recently made a medication error. There were two of us involved. I was the care taker of the patient and the other was the charge nurse and she was also assisting with some care of the patient. The error did fall in both of our hands. I was so upset and worried about the patient I wasn't too concerned with documenting since she said she would take care of it. She wrote in the patient chart and wrote up the incident report. I am and have been wondering if I should have written a nurse's note myself. Especially since I was involved and it was my patient? Should I ask to look at the incident report? Should I have written a nurse's note? I have been researching this on the internet for days but finding nothing that really helps. I have been so anxious lately and it's starting to affect my family. I asked the Director of nursing if I should make a note and she said the other nurse already did that I didn't have too. Please Help!

[RN403, BSN, RN]

If you are still able to write a late entry I would probably make a note myself even though the other nurse did already. I don't know if it is too late though...

Just write what med you gave and your follow up assessment. Don't mention the fact that it was an error in your nurses note. That is what the incident report was for. Just state the facts in your note.

For example:

"Lasix 40mg IV given. Vital signs stable. Insert other assessment data here... Physician notified. Will continue to monitor patient."

Best wishes.