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Discussion

Need help

Hi

i am certified nurse. I was taking care one pt and while I was going through pt previous day charting, I accidentally altered & filed charting on my name and today date. So what should I do now?

Featured Replies

  • Expert
Should I write a comment in box stating that I accidentally filed?

Yes.

Any mistaken or inadvertent documentation entry needs to be rectified with the facts.

  • Expert

Double Post Ghost.

Yes, this is a no biggie. A little comment in the appropriate box will suffice.

"Documented in error" or "Entered in error" is really *all* you need to do. Something like that. Any time I make a mistake - in my own charting or something to do with clicky boxes in the wrong place/wrong time that looks fishy I leave that behind. If I have to make corrections to a chart I also leave a note something along the lines of "Intra-op chart opened for correction". Though it's a facet of my job, I do chart a note when I open charts for audit purposes ("Intra-op chart opened for audit purposes"). I have a few other reasons I might access a chart - and I don't document those reasons unless there is something to document (hard to explain without giving specifics, they're just other kinds of audits that don't fall into the "chart audit" category).

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