Messed Up My Charting, Now I Am Scared!

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I just moved to a new department a couple of months ago. I am off orientation and for the most part doing okay.

Except last week!

I had a patient on multiple meds, who very suddenly began circling the drain. I did all the right things, as far as contacting the doc, following orders, following up, etc.. BUT, I realized after I got home that I did not chart a couple of bags of a continuous med on the MAR. I did chart appropriately on the I&O's but not on the MAR.

If I had returned to work the next night, I could have charted retroactively (with late notation), but that is only an option for 24 hours.

So I have unintentionally violated the Nurse Practice Act and I am freaking out.

Any suggestions??

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Specializes in OR, Nursing Professional Development.

Welcome to AN!

Did you try calling your workplace when you realized you forgot to document? In my system, there is an option for a nurse to document that a med was given by another.

Also, are you sure you only have 24 hours to do the documentation? It may be 24 hours for late documentation, but is there another option for an addendum? I know that with how my facility does things, I may get a request several weeks after a surgery to make a change (often to the wound class at the request of the infection control nurse or a missed charge).

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Thank you Rose_Queen! I will have to double check on the time limit. At the very least, I could put a nurse's note in the chart.

Thanks, I feel a little better:facepalm:

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