I forgot to chart something.

[dine saw]

Hi everyone. I'm a student nurse in my last semester, I'll be graduating in June. I had clinic yesterday and as I was getting ready for bed last night I realized I forgot to chart about the IV that I started. The pt needed another IV access because she almost coded (ICU pt) so the nurse asked me to start one on her and my instructor suggested running it TKO to keep it patent. I didn't chart any of this. What could happen? Charting sometimes seems scary to me

[kfarinato]

Can you call the unit and tell them? That's what I would do. Even experienced nurse occasionally forget to chart something.

[bunsterj]

You can call and see if someone will chart it for you...They would make an entry along the lines of:

Current date, time: Nurse Nancy, SN reports per phone that on 4/15/10 at 10:00 AM IV was started in (site) with (gauge angiocath), IV solution of (xxxcc of name sln.) was started at 21 cc/hr.------------------------Nurse Betty, RN

(or however IV starts are charted at your facility)

Hospital policy may dictate the exact wording. We had to start the entry with "LATE ENTRY" at one place I worked at.

Computerized entries usually have the option of "performed by" for procedures and such, or/and an option to enter non-checklist details.

It would be better to tell your instructor now, than to have someone else point it out later. This is something that happens all of the time, so it would be a learning opportunity for all.

[Virgo_RN, BSN, RN]

You can go back in and do a late entry. Just make sure you document it as such.

[clemmm78, RN]

The times when it hit me that I'd forgotten to chart something, I called right away to let them know. If it was important, such as an IV start, they would chart it as reported by me. If it wasn't as important and I was going back in within 24 hours, I would tell them and then chart it as a late entry when I got back on the floor.