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Discussion

Time frame.

Hello everyone, forgive me if I do this wrong but I'm a newbie. My question that recently I have been reprimanded for making a note on the 24 he report about a dressing refusal from a retired RN patient but for get to document it in a progress note until 8 hours later on my next shift. I was under the impression that there was a 24 hour window for documenting. Am I wrong to have thought this and I feel my repromandation was unnecessary.

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    Uh, you need to work on your english and grammar so we can figure out what you are asking!!

    Annie

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    We are technically allowed to chart things that are 24 hours old. The system literally locks the time and we cannot make entries for a time more than 24 hours in the past. However, we are encouraged to chart in real time if possible, and going back and editing something from a previous shift is a little frowned upon. As long as we are within our shift, no one really cares if we chart late. Sometimes patient care has just got to come first.

    Rules for charting are definitely facility-dependent. I would look over your facility's policy for charting.

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    If you can be identified by your user name suggest you change it to something more anonymous. As calivianya said rules for charting are facility dependent, but for legal reasons most require charting to be done within the shift. I would consider the reprimand a lesson learned not only about charting, but about the importance of knowing the hospital's policies. If I was new to the workplace, I would make time to familiarize myself with the policies.

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    I was on my phone and in hurry, how helpful you are. You are also rude.

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