Forgetting to document one of my every four hour neuro check

[daniela095]

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

[Emergent, RN]

OMG, the earth is going to stop spinning now!

[RNNPICU, BSN, RN]

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

[Triddin]

You could always do a late entry

[cleback]

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.

[daniela095]

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

[Night__Owl, BSN, RN]

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.

[daniela095]

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.

[MountainMedicRn]

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.