I forgot to chart some information that was pertinent to the patient and want to make sure my charting is complete. Is it legal to go back and finish documenting on a patient a day or even a week later?
Nancy Brent replies:
Documentation in the medical record or electronic record has been the subject of many responses in this column, so you might want to review them to gain additional information concerning your question. Some of those points can be re-emphasized in response to your question.
Remember that the patients medical or electronic record is a legal document, so it must be accurate and complete. Your facility’s policy should be followed strictly, when there is additional information about a patient that needs to be documented after your shift is complete.
Often facility policy requires that the entry in question be tagged in some way, for example, “Late Entry” or “Addition To Entry of (the applicable date). The date and time of the additional documentation must be noted when it is written and not backdated. Your signature and title should follow the entry.
There are many printed and Internet resources with guidelines on good documentation. Two hard copy resources are: Mosby’s Surefire Documentation: How, What and When Nurses Need to Document (2nd Edition) (2006) and Sally Austins, “Stay Out of Court With Proper Documentation”, 41(4) Nursing 2013, Pgs. 24-29.