PANICKING! How bad is this?

[RNcDreams]

Ever have this problem, where you realize a day or two later that you have left out some sort of documentation, something in report, etc?

I recently transferred a patient (age mid 80's) who ended up having a dissected aorta. They got 6 L of NS, 2 Units of O- neg, they were intubated, etc......

1. I forgot to write down that I gave a dose of aspirin (prior to confirmation of the diagnosis, was thought to be an MI for quite some time)

--------------> Is it appropriate to obtain the chart and write it in and sign it?

2. I forgot to fill out the blood transfusion sheet (but I documented in my note a set of vitals, when the blood went up, and on what line, and who I checked it with)

--------------------> Is it appropriate to fill one out? I have all the VS, start times, and can obtain the signature of the person who put it up with me.

3. I never double checked if the doctor wrote for all the meds he asked for

------------------------>> Is it appropriate to go back and write them all as verbal orders? I have each time, as I wrote them as they were given on the code sheet, and I know who gave each one.

4. The 3 other nurses working with me didn't sign off the meds they gave

---------------------->Is it appropriate to write them all, with "Given by ___" next to them?

AGHHH I am freaking out!!!

The patient was dropping his pressure and the family was getting hysterical, and in the heat of the moment I let these details slip and I am KICKING MYSELF.

How bad are these, and will I be safe if I go back and fill in the gaps?

[elizabells, BSN, RN]

Gosh, I don't know. I certainly wouldn't do ANYTHING to the charts without checking in with my Clin Spec. I've gone back and marked a med off on the EMAR that I was positive I'd given, but we're required to do that, and they actually post a list in the breakroom of people with overdue meds. It may well be okay, but I would definitely give someone a heads up. I also wouldn't mark off a med given by someone else, since you don't KNOW for a fact they were given if you didn't see it. If you do it, make sure to state "Late Addition". I did that once when I realized I'd gotten the name of the MD I notified about something completely wrong - there wasn't even a person by the name I put in my note. But again, I checked with leadership first.

[RNcDreams]

Gosh, I don't know. I certainly wouldn't do ANYTHING to the charts without checking in with my Clin Spec. I've gone back and marked a med off on the EMAR that I was positive I'd given, but we're required to do that, and they actually post a list in the breakroom of people with overdue meds. It may well be okay, but I would definitely give someone a heads up. I also wouldn't mark off a med given by someone else, since you don't KNOW for a fact they were given if you didn't see it. If you do it, make sure to state "Late Addition". I did that once when I realized I'd gotten the name of the MD I notified about something completely wrong - there wasn't even a person by the name I put in my note. But again, I checked with leadership first.

I did see each and every med that was given, so I do know for a fact! Should I still not write them?

[XB9S, BSN, MSN, EdD, RN, APN]

I don't know that I would go and fill the blanks, but I would make a retrospective entry in the patient notes if that is allowable where you work. Document it as a restropective entry and state why it is so late being documented.

I wouldn't sign for drugs given by anyone else but it may be worth getting them to do a retrospective entry as well.

[classicdame, MSN, EdD]

You need to contact your risk management person. Our hospital policy states that after 24 hours from your shift time you need permission from risk management to add to the medical record.

[traumaRUs, MSN, APRN]

I think you need to speak with your charge nurse or unit manager first. You can do an addendum to a chart but each hospital has its own policy for doing so. And...don't beat yourself up about it - it happens in the heat of the moment. An addendum made as a narrative is how I would do it that just lists the facts and that's it and yes, I would chart "medication XYZ given by Jane Doe, RN, especially since you saw the meds being given.

Good luck.