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Is this appropriate? (regarding charting)

Posted

Specializes in Oncology. Has 15 years experience.

We were painfully short staffed last night, and our patient acuity is fairly high at the moment. I pretty much spent the last 12.5 hrs having my booty kicked.

Now that I'm home and thinking over the night, I'm realizing my charting was woefully understated on one of my patients. I missed some fairly important points.

I'm going back tonight. Our EMR is divided into hours, and I can add charting on any hour (though viewing details will show what time the charting was actually entered). Is it appropriate to add charting on last night when I go in tonight?

David13, MSN, RN

Has 20 years experience.

It is always best to check the policies at your particular facility, but in most case it is certainly proper to add pertinent information to a patient's chart. If this information was omitted at the time that the original charting took place and should have been included at that time, it is generally labeled very clearly as a "late entry", so that there is no mistaking the time or context of the entry.

I agree with the above poster. There's a reason why late entries are able to be made. I think your situation would be appropriate.

Edited by April, RN
added info

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