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Dr. Cameron
Dr. Cameron, Doctor
Category: Medical
Satisfied Customers: 12910
Experience:  American Board Certified in Emergency Medicine and Ivy League trained. Medical Review Officer trained in Drug Testing
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I am a nurse and I just realized I accidentally documented

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Hello,
I am a nurse and I just realized I accidentally documented that a patient had a bowel movement today when she actually did not. Her chart now says her most recent BM was today but it was actually yesterday. Could this affect her care? I am worried she may become constipated because her chart says she had a BM more recently than she did or that she could be discharged without having another BM because her chart says she has had one within the last 3 days. She is hospitalized for altered mental status, so nothing related to bowel function, and I know MDs and nurses evaluate pts' bowel sounds, abdomen, etc every shift but I am paranoid! I am even dreaming about fecal impactions and bowel obstructions. Am I overreacting? Please be honest and thank you for your help!
Dr. Cameron :

hello

Dr. Cameron :

welcome to the chat

Dr. Cameron :

are you still there?

Customer:

Hello,

Customer:

yes I am still here

Dr. Cameron :

Well, if she had a history of bowel obstruction or fecal impaction, it may affect her care

Dr. Cameron :

but in general, normal BMs are from 3x a day to 3x a week

Dr. Cameron :

So no, it would not affect her care

Dr. Cameron :

That being said, you can make a late entry and correct it

Dr. Cameron :

That way the chart is correct

Dr. Cameron :

It is not a big deal, chart corrections happen

Dr. Cameron :

People are human.

Dr. Cameron :

And dates do get mixed up.

Customer:

That is why I worry because I don't work again for over a week, so I am wondering if I need to go in and fix it. She has no history of bowel obstruction or fecal impaction, but do you think either could develop because of this?

Dr. Cameron :

No, I do not think that she would develop either one of these conditions before of this

Dr. Cameron :

It is not a charting thing, it is a physical thing

Dr. Cameron :

And there are other signs and symptoms of fecal impaction and bowel obstruction

Dr. Cameron :

You can have an impaction after 3,4,5,6 days of no stool

Dr. Cameron :

I would call your superior and let him/her know that there is a chart correction which needs to be added and that you can co-sign it when you come back

Customer:

Very true! Ok, thank you very much! I feel a lot better now. Thank you for your help

Dr. Cameron :

you are welcome

Dr. Cameron :

I hope that I provided you with excellent service? :-)?

Customer:

Yes! I will say so in my rating =)

Dr. Cameron :

ghtgreat. thanks and have a good nic

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