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Late charting after a day

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Ming_max50

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Posted over 5 years ago

 

Is it acceptable if what you did yesterday in same patient will be charted today, an overwhelming day with high acuity patients was so mentally exhausting and i remembered only of the charting when I was at home because I see my brief draft notes in my pocket.

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Rate This | Posted over 5 years ago

 

Technically, you are suppose to chart that day's care on that day. But, I think we all have had busy days where it is just not possible to do all of your charting. As long as you chart chronologically and accurately it's acceptable, not what you SHOULD do, but what happens in the REAL world.

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Rate This | Posted over 5 years ago

 

I have done it. I am sure we all have. I would rather char it late instead of not charting it at all. If it is something minor then no need.

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Rate This | Posted over 5 years ago

 

If you do have to engage in this not-so-safe practice, be sure to mark your documentation as "late entry", EMRs do this automatically, but if you are still in a pen and paper environment, it's up to you to document appropriately. If it's important enough to need to document, don't you think any providers who review the chart after you've gone home need access to the information you didn't have time to document? I've seen - and worked with - many nurses who leave all of their charting to the end of the shift. I can't remember what I did and when I did it for that long - I STRONGLY encourage you to chart as you go. What if you get run over by a truck on your way back to work to chart the stuff you couldn't take the time for last night?