If a nurse enters a late entry, is this correct and what should be included?

• A. No. Do not chart late entries.
• B. Yes. Late Entry with the time of entry and the time of the event.
• C. Yes. Late Entry with the date only.
• D. No. Just add a note without times.

Answer: (B)

Recording both when events happen and when you document them is essential. If a late entry is needed, mark it as a late entry and include the time of the event and the time of the entry. This keeps the chart’s timeline accurate, showing exactly when care occurred and when it was recorded, which is crucial for patient safety and legal accountability. It’s also helpful to note the reason for the delay and sign the entry so the record clearly reflects who documented it and why. Entries that omit the event time or the entry time blur the sequence of events, and a note without times fails to provide the complete context for subsequent care decisions.