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Discussion

Length of time after a fall to chart?

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

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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..

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