Omission of Nurses Note.What Happens?

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Just curious, how does your facility deal with the ommision of a nurses note? Is it considered to be very serious, especially if it is not a recurring problem?Is it ususal practice to ask the nurse to put in a "late entry"?Has anyone ever been disciplined for the ommision of a nurses note?

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I forgot to note on one patient for a shift, did flowsheets but forgot to note. My nurse manager just had me note on my next shift and date/time the note

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It is a serious oversight but it happens. We just date the note on the day we write it but make sure the date and time are noted for the shift intended. As long as someone does not make this a practice, it usually does not mean a write-up.

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Specializes in Critical Care, Cardiothoracics, VADs.

We always charted "by exception" in my ICU - so if nothing changed from one shift to the next, you didn't write anything. If something did happen and you forgot to chart it, I never heard what happened.

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