Ask a lawyer: Documentation late entries


Question 1 of 2: Do late entries hold the same weight in court as multiple small timely entries?

Answer: A late entry is one which is not made as soon as possible after an event has occurred. It is required when it is not possible to document at the time of or immediately following an event, or if extensive time has elapsed.1 If a late entry is made, it must be completed in accordance with the nursing practice standards and documentation policies of a nurse’s institution or health authority.2 For example, the Saskatchewan Registered Nurses’ Association guidelines require a nurse to clearly identify and date late entries with reference to when the entry was made along with when the care or event occurred.3

A court will only determine how much weight to give a nurse’s documentation after it has been admitted as evidence. In determining how much weight to give a nurse’s documentation as evidence, the court will examine the frequency of the entries and how soon a nurse documented after care was provided, with an underlying assumption that the closer the nurse documented to the care provided, the more likely that documentation is to be accurate. In one case where a nurse made a late entry a day after she provided nursing care, the court found that:

Late charted entries are permissible if identified, and an entry made the day after the event is preferable to memory years later at trial. The [judge or jury] will simply assess the delay as part of the overall evidentiary assessment.4

This means that late entries may not be given the same weight as notes made as soon as possible after an event has occurred, but if they are clearly identified as such, they can be still be relied upon at trial.


1. College of Registered Nurses of Nova Scotia, Documentation Guidelines for Registered Nurses, Halifax: CRNNS, 2012, at 18. Note: Please refer to the specific practice standards or guidelines in your specific province.

2. infoLAW,Quality Documentation: Your Best Defence,” Vol. 1, No. 1, January 2007, Revision of May 1992.

3. Saskatchewan Registered Nurses’ Association, Documentation: Guidelines for Registered Nurses, Regina: SRNA, 2011, at 17. Note: Please refer to the specific practice standards or guidelines in your specific province.

4. Skeels (Estate of) v Iwashkiw, 2006 ABQB 335 at para 121.


Question 2 of 2:  
Do entries made at the end of a busy shift constitute late entries?

Answer: Whether an entry made at the end of a busy shift constitutes a late entry depends on the specific requirement for when documentation is expected to be completed in that specific practice setting. Generally, the greater the acuity and complexity of the patient population, the more likely a nurse is expected to complete minute by minute documentation. Examples of these types of practice settings include intensive care units (ICU), emergency departments and labour and delivery units. In less acute settings with stable patient populations, documenting at the end of a busy shift is generally an accepted practice.

Where nurses are expected to complete minute by minute documentation, entries made at the end of a busy shift may not hold the same weight as frequent entries made during the course of a nurse’s shift. A nurse must be aware of her or his professional standards, and institution or health authority policies concerning documentation.

In one case, the documentation of an ICU nurse, who reconstructing care provided over a three hour period by approximating times, was found to be inaccurate.1 While providing care to the patient, the nurse jotted down certain events on a piece of paper or pieces of paper whenever she had a chance. When she had an opportunity to sit down, she did her best to reconstruct what had happened in the preceding three hours by approximating the times. The court did not fault the nurse for putting emergency patient care ahead of her documentation, although the court did find that approximating times resulted in inaccurate charting and impacted the expert’s opinion.

CNPS legal advisors, who are lawyers, are available to provide advice to CNPS beneficiaries with respect to late entries.  Call us toll free at 1-844-4MY-CNPS (1-844-469-2677).



1. Dybongco-Rimando Estate v Lee, [1999] OJ No 1426 (QL) at para 10.

 

Published May 2015

 

THIS PUBLICATION IS FOR INFORMATION PURPOSES ONLY. NOTHING IN THIS PUBLICATION SHOULD BE CONSTRUED AS LEGAL ADVICE FROM ANY LAWYER, CONTRIBUTOR OR THE CNPS. READERS SHOULD CONSULT LEGAL COUNSEL FOR SPECIFIC ADVICE.

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