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Discussion

Going back to chart

Title: Going Back to Chart

I would just like a few opinions on this. I work at a pediatric office and mainly do triaging. Sometimes when I get home I remember pertinent information that should've been charted at the time of the visit. I usually work one day a week so I can't just add it the next time I am there, it would be too long after. I have called another nurse the next morning to add a note for me but I really don't like doing that cause it's not their work, it's mine. I have also gone back after my shift to add in the additional information, but I feel weird going back there when no one else is there. What are some of your thoughts on how I should handle this. Thanks for the input!

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    Speak to your nurse manager about how to properly go about this issue at your facility. Try charting as you go (if you can- I know it is difficult at times) as this will help to eliminate forgotten charting. If you cannot chart as you go, be sure to at least write down something that you would like to chart later, then, at the end of your shift ensure that you have everything charted before you leave.

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    Carry a small notebook with you and make notes throughout the shift so that at the end of the day when you are wrapping up your charting you can make sure you have included everything.

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