What are the rules and regulations for writing clarification orders and late entries?
Documentation of all nursing activities should be clear, concise, complete and contemporaneous with the activity/observation. The documentation should be done as soon as possible after the activity is performed, medication is administered, etc. Regarding late entries, a specific time limit or time frame for late entries into the clinical record is not suggested in resources consulted. The nurse must use professional judgment and be able to factually remember the activity/observation in question in determining what can honestly be entered into the clinical record, after a period of time. The date/time of the late entry must be current and reflect the date and time for which the entry is being made. The nurse should follow the facility’s policies and procedures on documentation of late entries. In the event an order clarification is needed, it should be given as a usual medical order, whereas, the licensed nurse is educated and competent, there is a medical order, the licensed nurse prac
