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Discussion

Time limits on charting???

I was under the impression (I'm not sure why) that nurses had 24 hours to make/add comments to their nurses notes. It seamed reasonable that after you go home you might remember something that you didn't chart or think of something you might want to add.

After a bad/emotional shift I went home got some sleep and did some thinking......went back to work the next day and added 1 short note. Now I am being told that I might be diciplined for this. It is a much longer story that I don't want to get into. But my question is this.....

Is it wrong/against the rules to add a note with in 24 hours?

ps this is computer charting so they can tell when the note was made.

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No, not as long as you note that it is a late entry and time that you wrote it and the time that it is in regards to.

You might check if your SBON addresses this issue specifically in your nurse practice act. While late entries are not a good idea, if you need to document something, you should do it, even if it's a late entry. Better late than never.

Unless somebody goes looking, I doubt the chart police will come after you.

As long as you document it as a late entry, there is no falsification going on.

It is important for the medical record to be accurate and factual. Late entries are legal and are required in order to make the record complete. In general a late entry should be made within 24 hours of discovery or sooner if possible. You really do not need to mention this to anyone as this is a commonly accepted practice. If the chart is not on your unit, then you must go to where the chart is, say medical records, and tell them that you need to make a late entry. You should date the entry with the current date and time and title the entry as "Late Entry" followed by the actual time of the event, then write your note. Your hospital will have a policy regarding late entries and you should reference it to make your decision. If you have to make an entry later than 24 hours after an event, you should discuss the matter with your manager before doing so.

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