While giving an end-of-shift report at 1915,a nurse realizes that a client's physical therapy session that occurred at 1030 was not documented.Which of the following is the correct method for adding this information to the client record?
A)Ask the oncoming nurse to make the notation for you.
B)Date and time the entry for 1915;then write "Late Entry (date-1030)" before making the addition.
C)Do not add the information to the chart,but complete an incident report.
D)Do nothing,since the physical therapist documented the session in the multidisciplinary progress notes.

Question

Quizplus · Accepted Answer

Entries should be made chronologically,starting with date and time,observation,intervention,and evaluation;it is essential to chart periodically throughout the period in which care is being provided so that significant changes in client condition are recorded as they occur.If pertinent data are not documented in a timely manner,late entries to a client's record may be permitted,according to facility policy.

While Giving an End-Of-Shift Report at 1915,a Nurse Realizes That