Late entry

Daisy4RN · Apr 8, 2020

At this point it might be a good idea to let your manager know of the situation. This could, or could not be a big deal depending on the pt, (did the pt need PT etc) . You need to know your P/P for late entry. In my experience it has been anywhere from 24hr up to a week, but usually 24hr. You need to also document that the entry was a "late entry". I dont see this being a big problem but IMO it would be better to attempt to rectify this now before it does turn into a big problem. I would not freak out, just do what you can to make it right. Give yourself a break you are new and mistakes will be made! Also, next time don't take for granted what someone else tells you (which I am sure you already figured out). Good luck!

crystalpan · Apr 8, 2020

3 hours ago, Daisy4RN said:
At this point it might be a good idea to let your manager know of the situation. This could, or could not be a big deal depending on the pt, (did the pt need PT etc) . You need to know your P/P for late entry. In my experience it has been anywhere from 24hr up to a week, but usually 24hr. You need to also document that the entry was a "late entry". I dont see this being a big problem but IMO it would be better to attempt to rectify this now before it does turn into a big problem. I would not freak out, just do what you can to make it right. Give yourself a break you are new and mistakes will be made! Also, next time don't take for granted what someone else tells you (which I am sure you already figured out). Good luck!

Thank you Daisy for your input. The patient told me that he uses a walker before admission (pt is axo x2 and psy history). I worked night shift, so many patients do not get out of bed as frequent as day time. We are using Epic, so when I changed it, it already shows my original assessment time and the time I edited (I changed in the Braden scale). Our entire floor is COVID now, so pt do not get PT/OT.

Thank you again for your time Daisy.

Daisy4RN · Apr 8, 2020

Even when charting was on paper it would have been obvious if you back charted. It is important to always add late entry for a number of reasons, one being to CYA. You should still try to fix your charting by adding a new late entry re the first one clarifying that it was a late entry. Also, next time if you get info from the pt that cannot be clarified/substantiated at the time of charting just add 'per pt' or 'pt states' . In this case " pt states uses walker at home for ambulation without difficulty". I would also f/u with the MD because the pt probably was walking at home until he came to the hospital (and chart that as well). Dont think that bc your floor is Covid that this cant come back to bite you, always CYA, even if they aren't going to get PT nobody can come back and say it was your fault.

crystalpan · Apr 8, 2020

Hi Daisy,

I went back to my original charting and changed it with a comment "uses walker per pt, but RN realized that pt is too weak to walk" in the braden scale part. How should I do a late entry properly although Epic does show date and time I edited it. I just want to cover my A** in case it comes back to me which I have been thinking all these after work all day.

Thank you Daisy!

Daisy4RN · Apr 8, 2020

If it were me, and without knowing your p/p, I would just add a note asap, something like this:

Date/time (whenever you go back): Late entry. Clarification of nursing note dated (add date of your original entry). Initial assessment of pt noted pt was able to ambulate with walker , pt assessment was updated on (date you already changed it) to add "pt stated he could ambulate..., RN realized pt to weak..." (word this exactly the same way you did in your previous charting). RN did not add "late entry" at that time. MD notified of pt status/change of condition/current condition, stated understanding and no new interventions (or whatever MD states).

Next time don't change your original assessment, just do a f/u late entry and note that MD was notified etc.

Good luck!!

crystalpan · Apr 8, 2020

Hi Daisy,

When I return to work (4/10), and I will ask my charge nurse to make sure what is the proper way to deal with this situation. I asked an experienced nurse last night about it, and she said just change the original charting (make sure put comment and explain why I changed the original assessment). Would that be too confusing to add a new note two days after editing the original document? (original doc 4/3, edited 4/7 and add a new note doe late entry 4/10?) I just want to make sure things are done in the proper way without any future "follow up". Thank you so much Daisy!!!

Daisy4RN · Apr 8, 2020

Your welcome!

It just depends what your facilities p/p say. Ours stated we were not to change anything on the admit assessment and just to do further f/u or notes as a late entry. Yes, it would be a good idea to ask your charge how to proceed (based on your specific p/p). You may even want to call them sooner to let them know, this doesnt sound like a big deal but you just never know what can turn into a big deal (I always prefer the 'better safe than sorry' way) . And as a (former) Charge I would much rather have a heads up and deal with a situation early on for the pt as well as the nurse! So if you called them today you could also add that to your next late entry (Charge RN notif...)and be done with it.

With more time and experience this will definitely get easier for you!!

Hope it all turns out well, I think it will be fine!

crystalpan · Apr 8, 2020

Hi Daisy,

I only had that pt for his admission, and I did not have him since then. I have been taking care other patients. He was always in my mind, so I remember that I forgot to update his assessment before I left my shift when I had him. I will call the charge nurse tonight and see what she will say. Template will be:

Clarification of nursing note 4/3. Initial assessment of pt notes ot uses walker to ambulate, pt assessment was updated on 4/8 to add "uses walker per pt, RN realized pt too weak to walk." Charge nurse notified------- (if charge nurse says dont worry about it, then do I even do a late entry?)

Thanks Daisy!

Closed Account 12345 · Apr 8, 2020

Just as a note, when an assessment finding changes, a late entry/addendum is not the correct approach.

At the time of your admission assessment, you were told he ambulates with a walker. That would be the correct thing to document for that date and time.

If later the assessment finding changes, and you realize he's now too weak to ambulate with a walker, you'd write your new finding for the new date/time.

Assessment findings evolve frequently, but, instead of undoing the initial finding, you should just document the most accurate information each shift. Think of it this way. If a patient had wheezes on admission, but clear lung sounds on your next shift, you wouldn't go back and remove the documented wheezes. The chart tells the story of the patient's progression, and it's significant if he comes in saying he can ambulate with a walker but is unable to do so the next week. Maybe the doc would want to order PT or something.

It'll be good to learn your organization's P&P for late entries. Either way, probably not a big deal this time!

crystalpan · Apr 8, 2020

Hi Faculty RN, MSN, RN,

Thank you for your input.

When I first admitted the pt, he told me he uses a walker at the facility. But later the shift, I observed that he might be too weak to walk and I read about his admission note later the shift and he had some sort of walking difficulty or not even able to walk. For report, I told the AM RN that pt said this but he could be non-ambulatory. I reminded myself to update that on the chart but it got too crazy later on and forgot. So I was thinking to fix it (might be too late now). Just try to cover my bu**. Thank you again.

Daisy4RN · Apr 8, 2020

23 minutes ago, crystalpan said:
Hi Daisy,
I only had that pt for his admission, and I did not have him since then. I have been taking care other patients. He was always in my mind, so I remember that I forgot to update his assessment before I left my shift when I had him. I will call the charge nurse tonight and see what she will say. Template will be:
Clarification of nursing note 4/3. Initial assessment of pt notes ot uses walker to ambulate, pt assessment was updated on 4/8 to add "uses walker per pt, RN realized pt too weak to walk." Charge nurse notified------- (if charge nurse says dont worry about it, then do I even do a late entry?)
Thanks Daisy!

I would still do a note even if your Charge says don't worry about it because you have already changed the admit assessment at this point so you need to clarify why, and also because it is your license (not anyone else's) and we all, even Charge RN's can have bad memories when/if this comes up later.