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Discussion

how to make correction to last entry in nursing note?

i charted in nursing note about an incident that had happened yesterday. when someone questioned about the incident the next day, i couldnt remeber the detail, so i asked a cena i worked with yesterday and i found out what i wrote down yesterday was not correct. so now i want to make a correction to yestdays entry but i dont know how to do that. can someone help me please?????

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What computer program are you using at work? Clinicomp allows to edit your own note, to make correction. Otherwise you might have to simply make a late entry stating your prior note was in correct. Then go on to give correct information.

i charted in nursing note about an incident that had happened yesterday. when someone questioned about the incident the next day, i couldnt remeber the detail, so i asked a cena i worked with yesterday and i found out what i wrote down yesterday was not correct. so now i want to make a correction to yestdays entry but i dont know how to do that. can someone help me please?????

i live in bfe and we do not have computer charting, so when i forget someting, i just write it in the nursing notes as late entry. i have been working 6 months now and no one has condemed me for it.

we always write Late Entry, put the date and time that the entry should have been charted, chart what is needed then sign.

Same here; for written notes we enter a correction as "late entry". I also add a small reference in the margin of the original note that says "see late entry" with the date and time of the addenda for clarity b/c you wouldn't notice a correction-which could be crucial- unless you knew to look ahead in the chart for it..

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