Medscape has an interesting question in their Legal and Professional Issues for Nurses–Staying Late to Chart: Is it Legal? Read it and let me know what you think about its implications for our own practice.
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Medscape has an interesting question in their Legal and Professional Issues for Nurses–Staying Late to Chart: Is it Legal? Read it and let me know what you think about its implications for our own practice.
2 replies on “Delayed Charting”
Speaking of charting…
I am seeing nurses, days and months (sometimes years)later, writing addendums, corrections, and documenting follow-up exams on their original forensic report forms. The original report forms (or even copies of the original)should not be written on again. If corrections have to be made, a separate sheet, entitled ‘Addendum’ can be utilized to document the page number, error/issue, and correction and, for follow-up exams, a copy of the original report or diagram describing the initial findings, can be marked and included with the separate ‘Follow-up’ paperwork.
Of course, if an error is made at the time the nurse is filling out the report, initially, the standard way to make a correction is to cross out, with one line and initial the item.
What are others’ thoughts on writing on the original report, at a later date.
Please, add a question mark (in your head)to the end of my last sentence.