As stated, documentation should occur as soon as possible after an event has occurred. When it is not possible to document at the time of or immediately following an event, or if extensive time has elapsed a late entry is required. Late entries should be defined by agency policy. Late entries or corrections incorporating omitted information in a health record should be made, on a voluntary basis, only when a nurse can accurately recall the event or care provided. Late entries must be clearly identified (e.g., “Addendum to Care”), and should be individually dated. They should reference the actual time recorded as well as the time when the care/event occurred and must be signed by the nurse involved.
A delayed entry may occur when two nurses enter data on the same patient. Delayed entries must be entered on a chart on the same shift that the care was provided and/or the event occurred, even if the information is not entered in chronological order. Delayed entries should be made according to agency policy.
In the event of a lost entry, the RN may be asked to re-construct the entry. Falsifying records is considered professional misconduct according to the definition under Section 2(as)(ix) of the Registered Nurses Act (2006) so the nurse must clearly indicate the information recorded as a replacement for a lost entry. Lost entries should be made according to agency policy. If the care/event cannot be recalled, the new entry should state that the information for the specific time of the event has been lost.