I was pulled to the ICU and assigned a rapid-response patient. The charge nurse asked me to get dopamine as the blood pressure was 49. I got it, she hung it. We weaned the patient off it, she got bicarb, finished her blood and was doing well. I scanned the dopamine late as there was no time to do so during the crisis. I received notification from my agency that I didn’t chart correctly as I changed the time I scanned the dopamine to the time it was actually given. She said I falsified documentation. Is it falsification if I gave it at 4 p.m. and scanned it at 5:30 p.m.? I charted the dopamine on a flow sheet, and frequent vital signs and my notes all reflect this. If this is not allowed, why would the computer allow you to do it? When is it OK to do late entry? When I became a nurse 22 years ago, it was on paper and you could write a note. Computers are different. I am upset.
Documentation in the medical record, whether by a hand-written entry or in an electronic medical record, must be accurate and complete. During a crisis, it is always difficult to scan medications given at the time, but this should be a goal.
When you are unable to do so, it is essential that your documentation software has a way in which to record a late entry. This allows you to correct any patient care information that is not accurate in an acceptable and truthful manner and that can be reviewed by those who will read the documentation. You need to touch base with the IT person in your facility (hopefully an informatics nurse) to learn how to handle late entries. If there is no procedure for this, the informatics nurse needs to be made aware of this so it can be incorporated into your software documentation system.
Even with hand-written documentation, late entries or any entry of correction must be labeled as such. Changing any information in the patient record without following good documentation principles can lead to legal and ethical problems.
A good reference to review is the American Health Information Management Association’s “Integrity of the Healthcare Record: Best Practices for EHR Documentation (2013).”