Are nurses allowed to add patient information to a chart after their shift is past?
A. Yes. But it must be done correctly or one will be guilty of falsifying a patient record. First, the information must be truthful. Example One cannot go back and make up vital signs and fill-in blanks because a clerk says no payment will occur without them. Second, check the facility policy and procedure and follow those directions on late entries. Third, if there is no policy or procedure it is probably most correct to identify the actual time of information addition and circle the time of the actual nursing act to show it is a late entry. Some people choose to add an “Addendum” to the chart. It is not uncommon for a nurse to forget to record something, remember it later and on return to work make a late entry. It is the normal course of business. One should never go back and change something on the original writing. Late additions/entries should be set off and placed in the next available chronological space.
