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How to Properly Document Times in Charts

May 14th, 2010 by – Derek Brocklehurst

If I do something at 0100, but cannot actually document until 0300, do I chart 0300 as the time of charting and summarize, putting at 0100 I did the procedure?

It is considered good clinical practice to chart procedures at the time they were performed. However, it is impossible to expect these standards to be met 100% of the time, especially in high stress situations or in facilities with high nurse-to-patient ratios. You should check with your nursing supervisor or institution’s documentation rules, as each nursing institution might have varying rules for charting. Even though it is good clinical practice to get in the habit of charting something at the time it was done, charting at 0300 that you performed something at 0100 is generally accepted.

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Posted in Common Nursing Procedures, On-the-Job Fears

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