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

[Sun0408, ASN, RN]

The fall should have been charted after the resident was taken care of, the family and MD were notified. Lesson learned, you did good with the other stuff but the charting should have been completed also as it is the most important.

[xoemmylouox, ASN, RN]

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.

Where I worked in LTC, in fact EVERYWHERE I have worked I was expected to chart what I did and what happened to my patients.. It didn't matter if I was the Charge Nurse that day or not... I have never heard of the Charge Nurse documenting a patient fall in the chart... I would not trust anyone but myself to do the charting. My patient = My responsibility. As a Charge Nurse I NEVER documented anything other than what happened to a patient I was directly providing care too.. Perhaps I was just taught differently? I could see the Charge Nurse writing the incident report, but not to do the charting..