How often does this REALLY happen?!

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I'm a newer nurse, trying to get adjusted. Well, I was thinking tonight how often do nurses forget to document something before they go home. If it happens, do you go back to work to document the next day? Do you just let it go? I'm just curious.

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Specializes in ER, Med/Surg.

You have to return right then and document it.

Ok I'm kidding. It depends on your facility. Although the quicker you do it, the fresher it is on your mind.

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Specializes in Sub Acute and Wound Care.

Well, it depends on where you work and the setting and the documentation style. I'm in a LTC/Subacute with paper charting and yes- ppl forget alot. Depending on the issue I may go back and chart the following day or shift. I try not to though- so I end up working a lot of overtime.

To help with remembering things I made my self a "Brain sheet" if you search for it on here you'll find several great ones. Anyway, I made a sheet with quick reference as to vitals, o2 info, Abt, therapy, iv's, g tubes, f/c, and as I get report I go down the line of my report marking off the room #'s of those residents- then when I go back to chart I go in room # order unless I have a major event happen mid shift that requires I stop everything to chart. Then when I chart I run thru the body sytems as well as whatever "extra" I need to chart on like ABT or therapy.

It's alot but it's the only way I've been able to figure out how to cover myself :)

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Specializes in Emergency, Telemetry, Transplant.

Depends what it is...

If I forgot to chart that they had a BM (if it is not 'abnormal' looking, bloody, etc.) I probably would not make a big deal of it.

On the other hand, I had a pt who was hypotensive when she got to our unit in the middle of the night. Depite 2 bolus doses she became more hypotensive and went to the ICU. The next day I went back to the chart to make sure I had all the necessary info there.

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I've called the charge nurse and at least made them aware that it had been done. I always double checked a mention of the addressed item was done if not, I'd document a late entry. CYA!!

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Specializes in LTC.

Every night I go home.. theres always something I forgot.

The world goes on.. just write a late entry.

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Specializes in Med surg, LTC, Administration.

I've done it soo many times, I lost track.

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Specializes in CEN, CPEN, RN-BC.

If it's really important, someone will call...

Someone always calls the minute before you fall asleep, when you're kinda in that lala land...

That is always when the phone rings and scares the crap out of you.

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Specializes in Med-Surg, Cardiac.

I forget something a lot. If it's important I write a late note next shift. If not I don't. I've occasionally called back to the floor to tell my replacement something I forgot.

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Specializes in Med/Surg.

In the past two years, I can remember one occasion where I forgot to chart something, that I had removed a dressing that was scheduled to be removed. I charted it the following night as a late entry. Otherwise I have a photographic memory and try to chart as things happen so I can say I generally forget very little.

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Specializes in Med/Surg, DSU, Ortho, Onc, Psych.

This happens quite often.

In Oz we have 72 hours to add entries into the medical record.

If u get home & do 4get sumthing, always call 2 let the staff know, & go in the next day 2 finish ur documention.

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Specializes in Long Term Care, Pediatrics.

I just put in a late note, unless it's critical, then I call and go back (once in my almost two years as a nurse have I gone back and I probably didn't need to, but CYA, CYA)

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