Is documenting response to PRN meds long after the fact legal?

[Lorie Brown RN, MN, JD]

Our facility requires a response to all prn medications, charted on the eMAR within one hour of administration. When this is not done, they give us a list of them to go back and do. Sometimes this is a few weeks after the fact. I am uncomfortable doing this because it is basically guessing if it is not mentioned in the nursing notes. Even as a late entry, is this legal if we don’t remember?

Hello documenting late meds,

Do NOT document anything that you don’t remember. That is false and inaccurate. It also is considered to be fraud. If you do need to go back and document a response to a medication, make sure you do it properly as a late entry. However, if you cannot remember it, it is better not to document than to document something that you cannot testify to under oath.

Lorie

[JKL33]

The answer above cannot be overstated.

NEVER chart about something you don't remember. It is lying and it is fraudulent as already stated.

Never, never, never.

Try to ensure that you are not an outlier; that is, not one of those with long lists of [what they consider to be] missed documentation. Do your best to document things in real time to their standards as much as you can.

If you receive your list and are unable to recall those things that they want you to document on, professionally decline to do so. If you are not having inordinate instances of "missed" documentation but they are pressuring you for fraudulent documentation and/or disciplining over the issue, time to find a new job. Seriously.

[Kooky Korky, BSN, RN]

Just thinking aloud - if there is no record of you or another nurse having given another PRN and if your or another nurse's post-PRN charting shows that the pt was doing well, might that help you to realize that the PRN was effective?