Late Entries and Corrections in Nursing Documentation
Sometimes you need to add information after the fact or correct a mistake. Both are acceptable when done openly; altering the record to hide what was originally written is not.
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Late entries
Label the entry as a late entry, record the current date and time, and state the time the event actually occurred. Write it as soon as possible and only from your own knowledge.
Correcting a paper record
Draw a single line through the error so it remains readable, add your initials, the date and time, and the reason if your policy asks for one. Do not use correction fluid, scribble out or remove pages.
Correcting an electronic record
Most systems have an amend or addend function that preserves the original and shows the change. Follow your facility's process; do not delete entries or ask someone else to change your documentation.
What never to do
- Backdate an entry
- Add to someone else's note
- Alter a record after learning of a complaint or incident