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Discussion

Med Doc. question

So, I did kind of an Oopsy. My patient whom was being discharged to Rehab originally refused his flu shot. It had already been documented on his MAR. When I was discharging the patient, he changed his mind and wanted the flu shot. So, I gave it, wrote a note on it anddocumented it in the paperwork sent to the Rehab. It just occurred to me that I forgot to document it on the MAR. This was a week ago (and I can't believe I thought of this now). What should I do? Should I call medical records in my hospital and change it or just let it go? I always dwell on these kind of stupid mistakes. ugh.

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The policy in our facility is this: If an addendum is > 24 hr, the nurse will contact Risk Management who will request the medical record. The nurse will then make the addendum, using the date of entry not the date of service. Sometimes Risk Mgmt. elects not to bother.

i WOULD personally let it go...I doubt any one would even pick up and on it, and the work it would take to fix it at this point is more of an irritant that anything.

it's just a flu shot, not worth it

wrote a note on it anddocumented it in the paperwork sent to the Rehab

Wrote a note in his chart, or just on the paperwork to rehab? I understand when a flu shot is given, the lot number etc needs to be charted in case of problems at a later date, if so and if not on the chart, I would pursue trying to get it on the chart possibly talking first to a supervisor.

You go to medical records, get them to pull the chart and make a late entry. You have to document what you did/gave to the pt in the medical record. A late entry is acceptable.

I wouldn't bother , I mean really, who is ever going to look thru that chart for that documentation?? If you are really concerned about it, call med records,pull the chart and document it. I personally wouldn't

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