Is "Back Charting" pt. information within 24 hrs of shift ending legal?

**canoehead, BSN, RN** · Jul 5, 2008

You can do it months later, but you need to date and time your entry so anyone reading will know when it was written. Make sure you clearly differentiate between the date and time you are writing and the date and time of the event.

Simpleplan · Jul 5, 2008

This was a practice question for NCLEX.

You come to work and notice the nurse before you didn't chart her last 3 hours. Should you?

A: Leave a blank space for her to chart tomorrow.

B: Continue where she left off.

I forget the other options.

The answer was B and the rational was she could chart a late entry.

allnurses Guide · Jul 5, 2008

This was a practice question for NCLEX.
You come to work and notice the nurse before you didn't chart her last 3 hours. Should you?
A: Leave a blank space for her to chart tomorrow.
B: Continue where she left off.
I forget the other options.
The answer was B and the rational was she could chart a late entry.

That is right - you never leave a blank space.

And yes, you can make a late entry (never heard it called "back charting") as long as you write the date and time you are making the late entry.

steph

LiverpoolJane · Jul 5, 2008

I have done this a couple of times - usually to document a conversation relating to the pt rather than direct care.

I always write in upper case "Written in retrospect" and under line it and the first sentence would be the date / time I was referring to with todays date and time in the margin.

CanuckStudent · Jul 5, 2008

Agree with everyone else...they can chart later, as long they write "late entry", sign it, and give details such as exactly when the chart was updated, and when the events actually happened. At least this is what we are told to do at my work, and that's what's outlined in the nursing textbook at work.

But I'm just a lowly student, what do I know?!

Better late than never is my motto...

elkpark · Jul 5, 2008

At every facility I've ever worked, it's been acceptable to make a late entry (even more than 24 hours later) as long as it was clearly identified as a late entry, with the date and time that the late entry was being made.

GIRN · Jul 5, 2008

I believe with computer charting, you don't need to date and time the late entry because anything you put in has the date and time you entered it. Anyone can look back and see when you put info in. (You just have to right click the entry and it will tell you who put in it and when.)

Tweety, BSN, RN · Jul 5, 2008

Not only can you write Late Entry...........most computer systems will automatically do this for you....if the next day I forgot to electronically chart something, I pull up my document and chart it. The computer automatically keeps a record "modified by Tweety at such and such a time".

Perfectly legal.

kiszi, RN · Jul 6, 2008

I do it all the time. Basic CYA stuff. I'm notorious for doing bare minimum charting, but I document the heck out of any "iffy" situations that might bite me later. So.. for example, I have a conversation with a family member whom I haven't met before about certain concerns. The next day I take report, and the night nurse says, "boy, that daughter was calling here all night! She's nuts about everything!" Well then I might go back and do a late entry documenting yesterday's interchange. Or, if God forbid, a pt goes out to the hospital (I'm in LTC) after my shift, I may do an entry detailing their condition at change of shift and any interventions I had done for them. Of course, ideally these entries should already be in place. Less suspicion that way. But I suppose it's better to have it as a late entry than not at all.

kiszi, RN · Jul 6, 2008

I should add..

It's not standard to chart on every patient Q shift in LTC. There simply isn't time. We take "charting by exception" to a whole different level here.:chuckle