How long can a nurse wait to document?

Documentation is communication between you and any other provider who reviews your documentation.   So, if the documentation is not in place you are not communicating.  Standard practice is to document as soon as you finish the task you were performing.  Realistically, shifts are super busy to the point that the first time a nurse is able to document is when the shift is over and another nurse has assumed care of that nurse's patients.  If that is the case, the best you can do is to document then.

The exception to waiting till the end of the shift to document is the Medication Administration Record (MAR).  Documentation of medication administration occurs immediately AFTER the medication is given. There is no waiting and also you do NOT document before administering the medication.  Actually, all documentation is to be done after the task is completed and never before.  I like to say "There is no Fixing-To documentation."  

Some nurses have the mistaken belief that they can leave the hospital and then document when they come back for their next shift and that is untrue and a habit that if caught will result in disciplinary action by the Texas Board of Nursing/BON.  Think about what documentation is used for; it is used to communicate to others when you are not present to tell them in person. So, if you are gone and the documentation is missing then no communication is happening and patient care is impacted.

The best practice is to do the task then document.   You are also likely to remember more important facts if you document timely. So, not only is it nursing standard, best for patient care, but is also more likely to protect you and give  you documentation you can rely upon in case something comes up later.

Timing for Giving Medications including Narcotics

 Nurses have said there is a  policy that you have an hour leeway to give medications. So, if a medication is ordered at 9 am you can give it as early as 8am and as late as 10 am.  First there is no national policy  supporting this practice. Second, you need to see with your own eyes that such a policy is in place where you work otherwise you are not protected by following this belief.  Do not rely on what others tell you.  Some hospitals do have policies that give 30 min to 1 hour either side of the selected time of administration.. You just need to be sure the hospital/clinic/prison/LTC etc  where you work has that policy.

If the medication in question is a narcotic you can end up being charged with giving a controlled substance outside the timing set by the prescribing physician.  If a physician orders a narcotic every 4 hours and you give it one hour early or even 30 minutes early, the Board of Nursing/BONs are saying you have failed to follow the physician order and gave a narcotic outside what was ordered by the physician's order.  When it comes to narcotics nurses need to wait until the stated time has occurred before giving the medication so that you are never too early and can avoid that complaint with the BON..

The same applies to scheduled medications that are tine specific.  You need to know what your facility's policies are and what the requirements are for that specific medication ( an example are antibiotics) and give the medication appropriately.  If the medication is strictly scheduled there is no time leeway.