# Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric ward that still uses paper records. Nurses write problem-oriented notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), and routine assessments are recorded on flow sheets using charting by exception. At 23:30 the nurse realizes that an episode at 20:15, when the client punched a wall, was never charted. The nurse writes it now as a late entry that shows both 23:30 and 20:15. Why is this method required? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=630152 > language: ko > subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations ## 문제 Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric ward that still uses paper records. Nurses write problem-oriented notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), and routine assessments are recorded on flow sheets using charting by exception. At 23:30 the nurse realizes that an episode at 20:15, when the client punched a wall, was never charted. The nurse writes it now as a late entry that shows both 23:30 and 20:15. Why is this method required? ## 보기 1. It shows the delay was approved by the charge nurse on duty 2. It turns the note into the ward's formal incident report 3. It lets the nurse write in the blank space left at 20:15 4. It keeps the record honest about when each note was written **✔ 정답** **정답: 4** ## 해설 A late entry is labeled as such and carries the current date and time as well as the time the event occurred, so the record shows truthfully when each note was made. Squeezing a note into an earlier space would misrepresent when it was written and weaken the record as a legal document. ## 심화 해설 A late entry is not simply a delayed note; it is a structured correction that protects the integrity of the medical record. When a nurse realizes that a significant event was omitted, the correct action is to document it as soon as possible, but with full transparency about the timing. The note must be clearly labeled as a “late entry” and include both the current time (23:30) and the actual time the event occurred (20:15). This dual timestamp is what makes the record legally defensible and clinically accurate. The reason this method is required is that the medical record must truthfully reflect when each note was actually written, not just when the event happened. If the nurse were to write in the blank space left at 20:15, the record would falsely imply that the assessment and documentation occurred at that earlier time. This misrepresentation can undermine the credibility of the entire chart if the case is ever reviewed in court or during a quality audit. Documentation serves as legal evidence, and any alteration that obscures the true sequence of events can be interpreted as an attempt to manipulate the record [1]. In psychiatric settings, this principle is especially critical. A client with schizophrenia who punches a wall may be escalating toward self-harm or aggression. The nursing team needs an accurate timeline to assess patterns, adjust the plan of care, and communicate effectively across shifts. If the note is squeezed into an earlier time slot, the interdisciplinary team may believe the event was assessed and addressed hours before it actually was, delaying necessary interventions. Key point! A late entry preserves the chronological truth of the record, which is essential for continuity of care and patient safety [3]. The SOAPIE format itself supports this approach. Each component—Subjective, Objective, Assessment, Plan, Intervention, Evaluation—is time-sensitive. When a late entry is added, the nurse should document the objective data (e.g., “client punched wall with right fist, no visible injury noted”) under the correct timestamp, and then note the current time when the entry is actually being written. This separation of event time from documentation time is what distinguishes an honest late entry from a falsified contemporaneous note. Charting by exception, which is used on flow sheets for routine assessments, does not change this rule. Flow sheets capture normal findings efficiently, but an unusual event like punching a wall falls outside the “exception” parameters and requires a narrative note. That narrative note, if written late, must still follow the late entry protocol. Watch out! Charting by exception does not mean charting only when convenient; it means charting only abnormal findings, and those abnormal findings must be documented truthfully regardless of when the nurse sits down to write. The legal weight of nursing documentation cannot be overstated. Records are often the primary evidence in malpractice claims, workplace injury reports, and criminal investigations. A late entry that clearly shows both times demonstrates that the nurse acted in good faith—recognizing the omission and correcting it transparently. In contrast, backdating or writing in a blank space left earlier can be seen as fraudulent documentation, even if the nurse had no malicious intent [1][3]. The charge nurse’s approval is not what makes a late entry valid. While some facilities may require a co-signature or notification, the core requirement is the dual timestamp and the “late entry” label. Similarly, a late entry is not the same as an incident report. An incident report is a separate risk-management document used for internal quality improvement and is typically not part of the patient’s medical record. The narrative note in the chart and the incident report serve different purposes and should not be conflated . In summary, the method of showing both 23:30 and 20:15 is required because it keeps the record honest about when each note was written, preserving the legal and clinical integrity of the documentation. The event time tells the care team when the behavior occurred; the entry time tells them when the nurse actually assessed and recorded it. Both pieces of information are necessary for safe, accountable, and legally sound nursing practice.References (research sources) - [1]Documentation in nursing practice.Research articleOwen K (2005) · DOI: 10.7748/ns2005.04.19.32.48.c3846 - [3]Voices From the Frontline: A Qualitative Study of Nurses' Experiences With Documentation and Its Influence on Patient Safety.Research articleAlghamdi RS, Albloushi M, Alshareef M, Alshamry H, Alabdulaal A, Alshakarah N, Alrashidi M. (2026) · DOI: 10.1155/jonm/6217086 ## 임상 시나리오 Late Entry DocumentationProtecting Legal Integrity in Paper Records When an event is charted after the fact, label it as a late entry and include both the current time and the time the event occurred. This dual timestamp truthfully reflects when each note was written. Never write in a blank space left earlier in the chart. Doing so falsely implies documentation occurred at that earlier time, which can undermine the record's credibility as a legal document. CautionIn psychiatric settings, an accurate timeline is critical for assessing escalation patterns. A late entry must be written as soon as possible after the omission is recognized, but never by altering the original chronological sequence. ## 핵심 개념 - **Late Entry** — A documentation made after the fact, labeled as such, including both the time of the event and the time the note was written. - **SOAPIE** — An acronym for Subjective, Objective, Assessment, Plan, Intervention, Evaluation; a structured format for problem-oriented nursing notes. - **Charting by Exception** — A documentation system where only abnormal or significant findings are recorded, using pre-printed flow sheets and standards. - **Legal Document** — The medical record's status as evidence in court; accuracy and honesty in timing are essential to its credibility. ## 같은 주제 문제 - [Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630051) - [Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630052) - [Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630053) - [Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630054) - [Situation: A 45-year-old woman with bipolar I disorder, current episode manic, is on the a…](https://mymerci.kr/pages/nclex_q.php?qn_id=630055) - [Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric war…](https://mymerci.kr/pages/nclex_q.php?qn_id=630151) - [Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric war…](https://mymerci.kr/pages/nclex_q.php?qn_id=630153) - [Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric war…](https://mymerci.kr/pages/nclex_q.php?qn_id=630154) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._