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My CNO and director want me to write a late documentation, but I was under the impression a late entry shows guilt or a cover-up. Is a late note necessary or should I leave the charting as it is?

Friday May 10, 2013
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Question:

Dear Donna,

A confused and unstable ambulatory patient I was caring for developed two skin tears while trying to get out of bed. I washed the wounds and wrapped them, but because the patient was very confused, he kept removing the wrappings and further injured his arms. I did not write about the skin tears in my documentation as I was very busy that night. The patient’s spouse arrived in the morning and wanted to see his medical chart, then proceeded to complain that there was no documentation. The CNO and my director want me to write a late entry note, as they are afraid the state will investigate. I was under the impression a late entry shows guilt or a cover-up. Do you feel a late note is necessary or should I leave the charting as it is? No one else after my shift wrote anything in the chart about the skin tears, either.

Concerned

Dear Donna replies:

Dear Concerned,

A late entry does not imply guilt or a cover-up. It sometimes simply can be something the nurse forgot to document. However, if there were ever a lawsuit related to this incident, the fact you did not chart it when it occurred likely would be questioned but is not automatically reason to assign wrongdoing.

I certainly can understand the concern and involvement of the family members and your administrators if your patient was injured, for whatever reason, and there is no documentation of what occurred. And of course being very busy is never an excuse (legal or otherwise) to omit important documentation. Likewise, what others did or did not document about the injuries after the incident is not relevant to your part in this or your responsibility.

The incident you refer to, as you describe it, likely should have been documented when it occurred. But because you did not document at the time of occurrence, for whatever reason, then adding the late entry in accordance with your facilities policies and procedures for doing so probably would be in order.

You may want to read this online CE course (it's free to read) titled Document It Right: A Nurse's Guide to Charting http://ce.nurse.com/60076/document-it-right-a-nurses-guide-to-charting. It addresses the issue of late charting and many other related issues.

Best wishes,
Donna


Donna Cardillo, RN, MA, well-known career guru, is Nurse.com’s “Dear Donna” and author of “Your First Year as a Nurse: Making the Transition from Total Novice to Successful Professional” and “The ULTIMATE Career Guide for Nurses: Practical Advice for Thriving at Every Stage of Your Career.” Information about the books is available at www.Nurse.com/CE/7010 and www.Nurse.com/CE/7250, respectively. To ask Donna your question, go to www.Nurse.com/Asktheexperts/Deardonna. Find a “Dear Donna” seminar near you: Call 800-866-0919 or visit http://Events.nursingspectrum.com/Seminar.