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Is it legal to enter the actual time an assessment was made and the corresponding patient information when charting is done hours later?

Friday July 26, 2013
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Question:

Dear Nancy,

In my facility we have always timed an entry as the time the assessment was made, not when we are actually charting it. If a blood pressure reading was XX/XX at 0158, generally we will chart the time as 0200 — even if we don't enter it in the record until 0600. Is this legal?

William



Nancy Brent replies:

Dear William,

Principles of good documentation state that when a nurse documents in an EMR or hard copy chart, the time of the entry must reflect the time the documentation is done. The entry can state something like: "At 0200, BP was XX/XX". This is an honest, accurate entry and there is no harm in doing this, unless your policy says otherwise.

Your example could create many issues if there was a problem with this patient and a suit were filed. For example, if the entry were timed at 2:00 p.m., would you remember when it was actually documented two or three years after taking care of that patient? If your facility policy states that the time an entry is done is the time used, and you did not follow that policy, this could raise a credibility issue for you and your employer.

There are many helpful references and texts on nursing documentation available for your review. Do an Internet search for "Nursing Documentation of Patient Care" for a list of some of those references. Documentation of patient care also has been the topic of some of the responses in this column. Reviewing them also might be helpful.

Sincerely,
Nancy




Nancy J. Brent, RN, MS, JD, is an attorney in private practice in Wilmette, Ill. This information is for educational purposes only and is not intended as legal or any other advice. The reader is encouraged to seek the advice of an attorney or other professional when an opinion is needed.