When adding medication information to another patient’s chart, nurse Lynette realizes she forgot to note the exact time she gave her previous patient, Mrs. Smith, her medication. Lynette finds Mrs. Smith’s chart and enters, “Medication was administered at about 10:30 am” in the record. Is this appropriate? Why or why not?
Answer
A
It is appropriate as long as the time entered is within 30 minutes of actual administration.
B
It is appropriate since the medication was not a controlled substance or pain medication.
C
It is not appropriate because a patient’s EHR must be absolutely accurate and complete.
D
It is not appropriate because Lynette did not ask Mrs. Smith’s permission to estimate the time.
Explanation
A patient’s health record must be accurate and complete. Since Lynette does not remember the exact administration time, documenting an estimate as if it were a reliable time could create an inaccurate record; she should follow workplace policy for handling the omission rather than guess. The time limit in A and the medication type in B do not make an estimate appropriate, and permission from the patient would not resolve the accuracy problem in D.
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