Late Entries in Nursing Documentation: What to Know
Sometimes you cannot chart when the care happens. A late entry is the honest way to add information afterward, but only if it is clearly labelled and carefully worded.
The short answer
A late entry is documentation written after the time the care or event occurred. Label it as late, record when you wrote it and when the care happened, include only what you actually know, and never change or delete the original record. The College of Nurses of Ontario standard, for example, says to indicate a late entry and the date and time the care or action occurred.
When a late entry is appropriate
- An emergency prevented real-time charting.
- You realize you omitted a significant fact from your own earlier entry.
- A system outage delayed documentation.
It is not a way to fill in blanks you cannot actually remember, or to improve how an event looks.
How to write one
- Label it clearly: "Late entry" in your system's required way.
- Record the current date and time you are writing.
- Record the date and time the care or event actually occurred.
- State only facts you recall or can verify from other sources, such as a monitor printout. Do not guess.
- Sign with your name and designation as usual.
Example (fictional patient)
Late entry
Late entry written 2026-03-14 at 1620 for care on 2026-03-14 at 1330. At 1330 Patient F reported chest tightness. Vitals taken at 1332: BP 142/88, HR 102, SpO2 96% on room air. Dr. notified by phone at about 1335 (time approximate; page log may confirm). ECG ordered and completed. Entry delayed because I was assisting with another patient's emergency.
Note how the writer flags the approximate time instead of presenting it as exact.
What to avoid
- Backdating or squeezing text into the original time slot.
- Altering, deleting or overwriting the original entry. Corrections must leave the original retrievable.
- Charting on behalf of someone else, other than as a designated recorder.
- Waiting longer than needed. Courts consider the delay when weighing a note, and the Canadian Nurses Protective Society (CNPS) notes that the closer to the care, the more likely it is to be accurate.
- Adding explanations or defensiveness that do not belong in the record.
Template
Late entry. Written on ___ at ___. Refers to care or event on ___ at ___. Facts: ___. Source of information, if not my own recollection: ___. Reason for delay (factual, brief): ___. Name and designation.
Check your local rule
Employers differ on how long after an event a late entry is acceptable and how it must appear in the electronic record. If the delay is long, talk to your manager or the health records department before you write it.
Where Fiabita fits
Fiabita's "Clean up my note" tool can help you reword rough notes into clearer, more objective language, and its SBAR handoff and incident-report tools ask guided questions so fewer details get lost under pressure. The output is a draft: you remain responsible for what goes into the record, and it does not check compliance with your regulator or employer. Do not enter information that could identify a real patient, and follow your workplace policy on which tools may be used.
FAQ
Q: Is a late entry a sign I did something wrong?
No. Late entries are an accepted practice when properly identified. Unlabelled changes or backdating are the problem.
Q: Can I add to a colleague's note?
Do not alter another person's entry. Write your own labelled entry with your own observations.
Q: How do I fix a wrong entry in an electronic record?
Use your system's correction or addendum function so the original stays visible, and follow your employer's procedure.
Sources and further reading
- College of Nurses of Ontario: Documentation practice standard
- CNPS: Ask a Lawyer, Documentation of Late Entries
- CNPS: Documentation for Nurses (guidelines)
Always check the current version of each source and your own regulator's standards; links and wording can change.