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Keywords

documentation, late entries, late entry, nurse's notes

 

Authors

  1. Murray, Michelle L. PhD, RNC
  2. Lieberman, Marcus PhD
  3. Olson, Kimberly CNP, RNC, MSN

Abstract

The purpose of this study was to elicit legal definitions and nurse definitions of a late entry. An exploratory study using a 34-item survey was conducted. Participants who attended an advanced fetal monitoring course conducted by the primary author were asked to complete the survey. Two hundred fifty-seven participants completed the survey. The sample included a physician, 13 certified nurse midwives, five nurse practitioners, and a licensed practical nurse. Two hundred and fifty-three participants were registered nurses. The median full-time nursing experience was 14.5 years. Nurses with an average of 14.3 years of experience used descriptive words, such as "out of sequence," to define an entry as late. Nurses with an average of 17.4 years of experience used minutes or hours to define when an entry was late. The average time for an entry to be considered late was 41.53 minutes after an event or action. Nurses who documented using a computer were significantly more likely to use a time frame to define an entry as late. There was no consensus on the definition of a late entry either by nurses or the courts. The majority of nurses define a late entry using qualitative descriptors. A well-accepted definition is needed to define when an entry is timely and valid and when it becomes so late that it lacks credibility.