My CNO and director want me to write a late documentation, but I was under the impression a late entry shows guilt or a cover-up. Is a late note necessary or should I leave the charting as it is?
A confused and unstable ambulatory patient I was caring for developed two skin tears while trying to get out of bed. I washed the wounds and wrapped them, but because the patient was very confused, he kept removing the wrappings and further injured his arms.