Forgot to document an output

[DH1234]

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?

[verene, MSN]

Breathe, this is not something you will get fired over. You did report in hand-off that he had urinated, so it is known, even if not documented. If you work the next day you can late document, but if you are off for a while I'd likely just let this go. We're all human, and sometimes things just don't get documented (even if they should) and most healthcare teams realize this. I think your idea of documenting in computer immediately after emptying is a good idea (and also writing it down on the brain). For things like this on my brain, I draw a line through it once I enter into computer so it is easy to tell what I have and have not documented.

[nurseburst, ASN, BSN]

I agree with verene here. It happens. I see a ton of strict I&O orders as we get a lot of CHF and Dialysis patients on our floors. It happens way too often unfortunately. I've seen in physician notes: "inaccurate I&O" and it can make it tough to know if a patient is OK to go home yet if the physician thinks they are still overloaded but more importantly accurate weights are even more important. But it's tougher with your patients on fluid restriction due to hyponatremia.

Give yourself a break, you are still learning and trying to get your flow down. You did tell the oncoming nurse the accurate output so don't worry!