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Reporting, Documentation & The Care Plan

The aide remembers at 4:00 p.m. that morning care given at 9:00 a.m. was not charted. What should the aide do?

  • A.Backdate the entry and sign it as if written at 9:00 a.m.
  • B.Add a late entry labeled with the actual entry time and the time care occurred
  • C.Ask another aide to add the entry using their own initials
  • D.Leave the care uncharted because the shift is almost over
Correct answer

B. Add a late entry labeled with the actual entry time and the time care occurred

Why

A late entry must be honestly labeled as a late entry, showing when it was written and when the care actually happened. Backdating, using another person's initials, or omitting the care falsifies or weakens the record.

Content outline: Role of the Nurse Aide - Documentation: Late Entries · From the Role of the Nurse Aide practice bank (RA-113).

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