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Discussion

Oops, forgot to chart!

I forgot to chart something yesterday at work. When I go back tomorrow, can I chart the task (with the correct date/time when it was performed) with a "late entry" comment?

Thanks!

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YES! That's SOP ---standard operating procedure in all facilities I've worked. Check your policy and procedure manual if needed as some electronic med records have special format need to be followed.

What NRS Karen said.

:)

In my facility, as long as the patient is still there all you have to do is enter the note with the correct date and time, since it is electronic it adds the note in where it is supposed to be. When we had paper charting, we would just have to right "OOS" before the post to alert people that the note was "out of sequence"

We were taught in school that it is ok within a 24 hour period.

What if it were after 24 hours? Were you not allowed to chart it at all? That sounds wrong.

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