Late Entries

Do you use 'late entry' charting at your facility? I was taught this charting in school but my facility won't let us do it. Everyone forgets something now and then!

[oneLoneNurse]

Yes, and though we don' t have a computerized nursing note portion we do have CPOE for weights, heights and charting of meds. We all make mistakes and if the system can't accomodate for that there is a problem.

[jemb]

If you can't use 'late entry', what do you do? How do they expect you to document something you did but forgot to chart at the time?

An alternative that I have used is to chart the current time, but reference the prior time and detail. For example, in today's charting, you might write at 1400: 'Pt c/o back pain on 9/19/04 at 1330, but refused pain medication at the time, stating that she did not want to be 'drugged' when her visitors arrived later that afternoon.' Awkward, yes. but willl cya if needed.

[sharann, BSN, RN]

If you can't use 'late entry', what do you do? How do they expect you to document something you did but forgot to chart at the time?

An alternative that I have used is to chart the current time, but reference the prior time and detail. For example, in today's charting, you might write at 1400: 'Pt c/o back pain on 9/19/04 at 1330, but refused pain medication at the time, stating that she did not want to be 'drugged' when her visitors arrived later that afternoon.' Awkward, yes. but willl cya if needed.

This is a very good alternative, and I have done it in the past. As long as it is not documented 3 days later, in which case you need a backup plan for certain.