Making corrections to a computerized medication record

[tolerantgirl]

I took report from a nurse who reported to me that she gave prn pain medications, but when I went to give the pain medication, I noticed the prn medication was not documented ( was not scanned). I checked to see if the medication had been removed and it had. I told my charge nurse and she told me to chart the medication for her and chart that she had given it. Is this ok to do? And how long do you have to make corrections to a medication record, computer or paper?

[Emergency RN]

I would chart the medication as "given" and then append a notation "as administered by and then reported to me by RN so and so"

We have this problem all the time with floats or per diems who don't have password access to our electronic charts, and many times we have to chart for acts that they performed. It's not a perfect solution obviously, but it is one that management allows.

[Simply Complicated]

I have gone back and documents, but I put a note right in there. Given per so and so, medication shows as removed at X time. Just like anything else, if you are documenting it as it is, you are covering your own butt.

[anITNurse]

Most systems have a way to chart by proxy, if your system does not it should have a way to add a comment/note to the charting. As to how long you have to modify or update documentation - that is usually a preference that is set by I. S. per the hospital policy. Our nurses have 4 days (96 hours) to make additions/changes. Nurse managrs may ask for a temporary extension on that for special circumstances.

[anonymurse]

I have driven back to work to chart something I forgot when it's important enough to me.

I expect others to do the same, if it's important enough to them.

If I didn't do it, I don't chart it.

If I didn't see it, I don't chart about it.

Whatever I do, I NEVER CHART FOR SOMEONE ELSE.

[Up2nogood RN, RN]

If you charted for the previous nurse that would be exactly the same as you signing HER name to a paper mar. Don't do it. I would make a note in my charting stating the last time the prn was given per verbal report from previous nurse. I refuse to chart anything given,med, or task for another coworker (even vitals). I've had CNA's ask if they could chart a set of vitals since we were both in the pt room and I had their record pulled up on the bedside computer. I just say no but I'll log out so YOU can enter them.

[healthstar, BSN, RN]

Hospitals have different policies about documentations, some hospitals want you to document right after you administer the meds ( that way you won't forget the med names ) , some at the end of the shift, some 24 hrs. What's scary is that If the meds are not documented you didn't give them.

[solneeshka, BSN, RN]

Our system has a way for us to chart by proxy (you check off "Administered by someone else"), but doing that triggers a message to that other person that they must respond to the next time they log on before they can do anything else (they either have to approve it or not). So you are not taking responsibility for the med having been given, but you are getting in onto the MAR so the med is not accidentally over-administered. If you charted it and the person who you charted as the one who gave it is not willing to approve that documentation the next time they sign on, then it comes off the MAR and you're not on the hook.

I still don't like doing that since just because the med was removed that doesn't mean it was actually administered. They might have not given it and then forgot to return it. What I'll usually do is, if someone reports they gave it and the machine shows it was taken out, I'll ask the patient if they received it (this is almost always PRN pain meds or IV abx, something the patient is more likely to remember than other meds). If all that matches up, I'll do the "Administered by someone else."

I wouldn't in a trillion years chart it under my own name, even if the other nurse told me herself that she gave it. I wasn't even there at the time! Don't want to try to defend that one in court 5 years down the road.

[wooh, BSN, RN]

I have driven back to work to chart something I forgot when it's important enough to me.

I expect others to do the same, if it's important enough to them.

If I didn't do it, I don't chart it.

If I didn't see it, I don't chart about it.

Whatever I do, I NEVER CHART FOR SOMEONE ELSE.

I don't chart what I didn't witness/do. I chart what I did witness, "Reported given at 1520 by Last Shift,RN." I don't chart that she gave it (I don't know that she did) but I chart that she said she gave it.