Administrative & LegalQuestion 97 of 100
A medical assistant forgets to chart a wound care treatment until the following morning. How should the entry be made?
a.Insert it in yesterday's space so the sequence looks unbroken
b.Ask a coworker to sign it with yesterday's date
c.Leave it undocumented, since the care was already given
d.Make a late entry dated today, clearly labeled as a late entry and referencing the date and time the care was actually provided
Explanation
A late entry is charted on the current date, labeled as a late entry, and states the date and time the care actually occurred, which preserves an accurate legal timeline. Backdating an entry or having someone else sign for the work is falsification. Leaving care undocumented creates the legal presumption that it was never performed.
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