I am currently on orientation, and I came home to realize that I forgot to document one of his outputs. I am freaking out because he is on strict I&Os and do not want the doctors to think he is not urinating a lot. I mentioned in my hand off report how many total mL he produced last night, but I just forgot to document. And I know everyone says if you did not document it, it did not happen.
I do not know what to do in this situation. Sometimes another patient calls out before I have time to document it, so most of the time that is why I forget. Therefore, I typically write a remainder on brain sheet to document it but I guess I overlooked it. I know in the future I should just take the time to document the output then and there, so I do not forget again. Do nurses get fired for this? Should I try to see if I can do a late documentation when I get to work. Or should I just let it go?
I am currently on orientation, and I came home to realize that I forgot to document one of his outputs. I am freaking out because he is on strict I&Os and do not want the doctors to think he is not urinating a lot. I mentioned in my hand off report how many total mL he produced last night, but I just forgot to document. And I know everyone says if you did not document it, it did not happen.
I do not know what to do in this situation. Sometimes another patient calls out before I have time to document it, so most of the time that is why I forget. Therefore, I typically write a remainder on brain sheet to document it but I guess I overlooked it. I know in the future I should just take the time to document the output then and there, so I do not forget again. Do nurses get fired for this? Should I try to see if I can do a late documentation when I get to work. Or should I just let it go?