A nurse realizes that an assessment completed earlier in the shift was not documented. Which action is appropriate?
1Backdate the assessment to the time the care was originally provided
2Add a clearly labeled late entry with the current date, time, and author✓ Correct answer
3Delete nearby notes and recreate the sequence with the missing assessment
4Ask the next nurse to document the assessment during the following shift
Explanation
A delayed entry must be clearly identified and show its actual date, time, and author while preserving the original record. Backdating, deleting original content, or asking another nurse to document care undermines record integrity.
Quick answer Enter the omitted assessment as a labeled late entry using the current date, time, and your identity. Keep the original record visible and follow facility policy.
Why this is correct The record must show what care occurred and when the documentation was actually added. A labeled late entry creates an audit trail that connects the author and current timestamp to the omitted assessment without making the record appear contemporaneous.
Easy analogy or mental picture A late entry is like adding a dated footnote to a signed timeline rather than rewriting the timeline. The footnote preserves transparency; the image does not replace facility-specific electronic record procedures.
Memory hook Late documentation stays honest: label it, use the current time, identify the author, and preserve the original record.
NCLEX decision rule When documentation is delayed, correct the record transparently instead of backdating or erasing. Identify the addition, its author, and its actual entry time, and use the organization's approved correction process.
Why the other choices are wrong Backdating makes delayed documentation appear contemporaneous. Deleting surrounding notes damages the audit trail, and another nurse cannot document an assessment that the first nurse performed.
References
[1]
NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing
[2]
CMS: Amendments Corrections and Delayed Entries in Medical DocumentationCenters for Medicare and Medicaid Services, Transmittal 12633