Forum - Questions & Answers
Changing medical records.
Looking for rules on changing and adding to er records by nurses, start and stop times of IV's. Nurses now adding times day or two later.
thanks for help.
re: Changing medical records.
every entry in the medical record must be dated and timed. It should reflect the time the procedure was done if the entry is not made contemporaneously. There is no time limit for late entries, except common sense.
re: Changing medical records.
This is an educational opportunity. there is no reason for adding the times routinely after the service. how good is their memory, honestly? 1:05 or 1:10? Once you've educated the nurses, then the expectation has to be that they document start and stop times as they happen.