While giving the end-of-shift report to the oncoming nurse, a nurse realizes that she did not document a procedure performed on a patient during her shift. How should the nurse document this in the patient's chart?
Explanation
•When documenting an event or procedure that occurred earlier in the shift, the nurse should indicate "late entry" and document the time the procedure or event occurred, writing in the next available space of the chart. Do not leave blank spaces in the chart between entries, as this allows further entries to be entered out of order.
Incorrect options:
•It would be irresponsible and unethical for the nurse to ask another nurse to document a procedure or event that occurred on her shift.
•The nurse should not simply document the procedure on a blank area of the previous documentation. Instead, a "late entry" note needs to be made with a specific time indicated.
•The nurse should not use asterisks when documenting in the patient's chart.