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Discussion

nurse documentation

I'm a nurse in New Jersey and have been having this running discussion that nurses are allowed to make an addendum up to 24 hrs. I say we can and several other nurses on staff agree but there are a few that say that once your done and your shift is over there's no going back. If an addendum is allowed where does it say that we can do this. Is this NJ nurse policy?

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    • Featured Replies

    You can almost always make a "Late Entry" as long as it is documented as such. i.e. 5/2/2010 2103 Late Entry: 1700 bedside paracentesis by Dr. Blank. 1300 ml clear, straw colored fluid aspirated. Sample sent to lab. Covered with bandaid. Pt tolerated without complaint. My hospital 'closes' the electronic chart 72 hours after discharge.

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    • Author

    that what I thought but is there any written documentation that this is allowed and acceptable practice. I'd like to be able to print out something to show my coworkers.

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    You might check with your BON or Standards of Practice for NJ. Or check with your hospital's quality dept or lawyer.

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    Agree with OP; ask Risk Management. Every state is different; facilities may have their own policies.

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    that what I thought but is there any written documentation that this is allowed and acceptable practice. I'd like to be able to print out something to show my coworkers.

    *** Just ask the simple question to them "Where it says you can't?" so if there's such thing they will show it to you and you'll get the right answer :)

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    • Experts

    Your employer/facility should have a specific policy & procedure about this, which is what you should follow.

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