Length of time after a fall to chart?

[snowbug0818]

I had a resident fall today at 1:10 I leave at 2:00, I called the family, the doctor, put it on the 24 hour report, put the 72 hour neuro checks in place and did the incident report. All good right. NO I forgot to put it in the residents chart. Just got a call from my DON at 4:30 to tell me this. How long do you have to chart such things? I always thought it was 24 hours. Am I mistaken? I am going back to work tomorrow morning at 6a so it will be done in 16 hours? just wondering

[amoLucia]

You sound like LTC from everything you did. But ..... the chart is the official record of pt care and as we've all been taught ---'if it ain't writen, it ain't done'. IMHO, you should have done the charting.

It's PIA. But think about it. The nurse following you has to document for continuity of care and there's nothing there to chart behind. In this type of situation, I usually have to write my first sentence something like --- "Reported from previous shift that pt fell" (or had GTube replaced, or sustained laceration on left arm, etc). Nothing special, no more, no less. But that explains WHY I am charting.

And to be bluntly honest and frank, I'm not going to leave any blank space for you to fill in your note because of the potential possibility that you could write a note that conflicts with or contradicts mine. I don't want to leave myself open in any way if that chart goes to court. You will just have to write a late entry. So you really should have written your note. I have seen too, too much risky documentation in my long career.

And God forbid, what happens if you couldn't make it back in to finish your charting??? Lawyers just LOVE IT when documentation is out of sequence, contradictory or missing!

Please, DO NOT TAKE THIS PERSONAL! It was just not a good idea to delay your chart documemtation. You started neuro checks (as in possible head injury). Your DON quickly was checking out the situation. Did this pt go to the ER?? It was just too big a risk to not chart.

[Sparrowhawk]

Chart in th chart and leave the Incident Report for later if you have to. No, ther's not 24 hours to chart on it cause the next shift has to and the next....and the next....so really you should have come back in and charted it. :)

[JustBeachyNurse, LPN]

I've never heard that has 24 hours to chart anything, never mind a significant event such as a fall. Perhaps 24 hours to complete the incident report if proper administrators/supervisors are notified about the incident and immediate action is taken. Since you've already left wihout charting, please be certain to check with your supervisor or managemen so that you can properly chart a late entry. It must be dated as today as backdating is considered fraudulent

[Juankiters08]

Charting is the siingle most important thing you should do that you forgot to do........like someone said, if it wasn't charted, it didn't happen....I usually carry a notebook around and take note of the important things that happen if I'm a little swamped with other things, then when I do get time to chart, I look back at my notes and go from there. Carrying a little notebook always helps me, but that whole 24 hour grace period thing is kind of siily.

[TheCommuter, BSN, RN]

In the state where I live, you have up to 48 hours to make a late entry in the chart. When you chart, you must note that you are making a late entry for whatever date and time the fall took place.

[minnymi]

i have no clue because i haven't stumbled across this problem, but wouldn't the charge nurse be able to chart the incident in the resident's chart if she was there when it happened?

[Sparrowhawk]

LTC you are the charge nurse....

[caliotter3]

AmoLucia said it well.

[minnymi]

LTC you are the charge nurse....

how so?

i don't work in LTC, but i did clinicals in LTC and there were LPNs who had patient loads and passed meds and then there were RNs who were "charge."

[BrandonLPN, LPN]

how so?i don't work in LTC, but i did clinicals in LTC and there were LPNs who had patient loads and passed meds and then there were RNs who were "charge."

It all depends. Where I work, some evenings there is me passing medsand a RN "in charge". Other evenings there's just me. Thus those nights I'm "charge" simply by virtue of being the only licensed person there. If there IS a charge nurse while I'm passing meds, of course I expect her to do all the charting. She's not paid to sit at the nurses station and look pretty! If the OP had a charge nurse present on the floor who didn't have her own med pass/patient load, it was that charge nurses responsibility to do ALL incident reports, phone calls, charting etc.

[ronda919]

I work in LTC, starting corrections next week though. (Partly bc of all the charting....) Anyway, like others have posted, staying, and charting would have been the best thing to do. I spend almost everynight staying after work to do the dreaded charting! I would love to just clock out and go home, but with your license there's so much that could go wrong. We use computer charting, and if you do a late entry the exact date and time you write it automatically shows up, that's a lawyers dream if the case went to court. Then u have the issue of everyone charting behind you.

But its ok, just use this as a learning experience,