A nurse remembers an important assessment finding several hours after completing the original note. What is the correct way to document it?
Correct answer: B. Add a dated and timed late entry with the current time
- A. Enter it in the earlier time slot without explanation
- B. Add a dated and timed late entry with the current time
- C. Ask another nurse to add the finding to the record
- D. Write it on a separate paper and keep it with the chart
Explanation
A late entry should be clearly labelled, dated and timed, and should state when the assessment actually occurred. Changing the original time or using a separate unfiled note can damage the accuracy and legal reliability of the record.
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About Documentation, Reporting and Communication
Documentation covers accurate, timely and objective nursing records, charting formats, incident reports, medication records, confidentiality and legal accountability. Communication includes therapeutic listening, questioning, empathy, handover and reporting using a structured method such as SBAR, while distinguishing subjective patient statements from objective observations.
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