When to turn in nursing notes

[crscott08]

Does anyone know when nursing notes are to be turned in? Is there a law stating they have to be turned in within so many days, or is that more like an office protocol? Thanks.

[nurseprnRN, BSN, RN]

I don't know what you mean by "turned in." Standard of care is that notes are entered in the chart (electronic or paper) concurrent with care, before the nurse leaves the premises at the end of his/her period of responsibility (shift). Late entries must be labeled as such and a reason given for why they were made in an untimely manner.

"Standard of care" will be binding in court even if not enshrined in statute. However, timely charting is part of the responsibility you will find in your nurse practice act, which is law.

[crscott08]

In this practice, we do not have electronic records. Everything is hand written. The nurses are Hospice nurses and go out to the patient's home.

[nurseprnRN, BSN, RN]

Then they should complete their charting by the end of the day, like other home care nurses must.

[crscott08]

Ok, awesome! Thank you so much for your help!

[DidiRN]

Moved to Hospice Nursing for best response.

[MomaNurse]

Check agency policy but they should be done end of day, latest next day. Make sure you are charting communication of all changes to your team.

[Nascar nurse, ASN, RN]

My office requires that we turn paperwork in every couple days. My notes are completed at time of visit but I only get over to the office every couple days anyways.

[curiousauntie]

Our office wants timesheets turned in within 48 hours and our notes must be with the timesheet. We also are NOT e-charting. All paper, all the time, and I have the carpel tunnel to prove it!