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Forgetting to document one of my every four hour neuro check

Nurses   (1,504 Views | 8 Replies)

1,767 Profile Views; 22 Posts

This happened yesterday late in the afternoon. Woke up earlier and realized I didn't document my last neuro check after I did it. I remember getting pushed into doing something else and never remembered. I'm on orientation, should I call my preceptor and tell them or is it too late considering it was a while ago. I feel so stupid :(

Edited by daniela095

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Emergent has 25 years experience.

7 Followers; 2 Articles; 2,861 Posts; 66,074 Profile Views

OMG, the earth is going to stop spinning now! ;)

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RNNPICU has 13 years experience as a BSN, RN and specializes in PICU.

1,057 Posts; 12,329 Profile Views

Probably too late to document it now. Next time you see your preceptor, tell them. Work on it and remember the next time to document

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380 Posts; 3,417 Profile Views

You could always do a late entry

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1,381 Posts; 10,573 Profile Views

Man, I wish I had that Hangover meme at my fingertips...But did the patient die?

Seriously, no one is going to check your charting unless there's an untoward event, which sounds like there wasn't. And I think there are limits for pate entries.

Anyway, take it as a lesson learned and move on.

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22 Posts; 1,767 Profile Views

Thanks. I know there is someone in the hospital who looks at the neuro checks I just hope it isn't a big deal if they see I missed

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Night__Owl has 3 years experience as a BSN, RN and specializes in ICU and Dialysis.

93 Posts; 628 Profile Views

I would go back and make a late entry next time you are with your preceptor. You should be able to. It''s not something to call your preceptor about, unless you had forgotten to chart a change, which it doesn't sound like is the case.

The only time it would matter is if the next shift nurse assessed a change, looked back in the documentation, and could only find a "last known well" of 8 hours previous rather than 4. But if you're doing a thorough bedside report, even that wouldn't be a problem.

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22 Posts; 1,767 Profile Views

Thank you makes sense. I am confident that the patient had no change when I assessed her so hopefully it stayed that way and no one will give me a problem for the documentation. I am new and still working on my time management.

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15 Posts; 127 Profile Views

Ha! Nice, its good that you care. I don't thnk your preceptor will give a hoot. Get ready to remember that you forgot something over, and over again. Make systems that help you to remember.

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