If You Didn't Chart It, You Didn't Do It
Nursing 101. This phrase has been drummed into your head since your very first nursing course. And your instructors hovered to make sure you charted everything just as you did it. That was because you were working under their license. Now you're on your own and things have gotten a little lax because you're always so busy and feeling overwhelmed.
You finally have a few days off, and your flight just took off for Hawaii for a long weekend. Suddenly you remember you forgot to document that you gave Mr. Jones his last step (enemas until clear) of the barium enema prep just before you left the hospital to get to the airport. Now it's too late, you can call when you land, but that won't be for several hours. You know that no one will believe Mr. Jones when he tells them he's done; this is the second time around, and he didn't prep himself right the first time. The doctor was furious and several things had to be delayed.
The medical record is your proof that you did or did not do something. Always document as soon as possible especially when administering medications and treatments. Remember to include accurate information regarding site, route, and the patient's response or outcome. If the patient refuses a medication or treatment, be sure to record this information and that you have notified the M.D.
True to form, no one believes Mr. Jones, and so he's mad at you and your supervisor is disappointed. The nurse who now has to stop what she's doing and prep him is mad as well. While no real harm has been done, everyone has been inconvenienced to say the least. And when you call them several hours later, they're not happy with you all over again. Imagine if this was a whole different scenario and medication was duplicated or skipped entirely because the medical record was incomplete and basically inaccurate. What if Mr. Jones decides to sue over this matter: How can you prove that you did give the prep?
You can go back and amend your documentation at any time as long as you can honestly state that you remember the event. You must clearly state that this is an amendment and include the time and date that you are amending the record. If you are changing a statement because it is erroneous, you can mark through it, initial it, and reference where to find the amendment. Make sure that the information being corrected is still legible. And again make note in your amendment of the time and date of the new entry.
In the event that documentation is destroyed or lost, and you have been asked to re-create it, be sure to make note of how accurately you remember the data and that this is a re-creation to the best of your knowledge. Again, date it with the new entry date and time. Always sign your name and credentials to any documentation you write.