Hospital administration implements a computerized approach to patient medical records and the guiding committee recommends a date/time stamp that automatically logs the time of entries into the chart. A recommended feature is an option to set the clock back up to eight hours to permit late entries.This raises a number of concerns: the purpose of data entry into patient records, current practices of caregivers, and the desired best practice demonstrating desired institutional values. The purpose of data entry in patient records is to provide accurate and honest documentation of treatment and the context in which it took place. Charts are the basis for confirmation of care and medical billing. The patient, all caregivers, the hospital, and third-party payers are vitally concerned with the information the chart provides.

During a shift, time may not permit immediate and complete data entry. How do we document care, in a timely manner that provides all caregivers, supervisors and billing an accurate, honest picture of the care?

If we value accuracy, entries must be factually correct: the chart must contain all pertinent information, entered on designated forms and in proper order for the right patient. What data entry behaviors produce the common mix-ups in charting? How is error related to the time of entry?

Honesty requires that the context of care be stated truthfully. Unanticipated consequences result from less than factual entries. Oral reports are insufficient.

Best practices aim to increase patient safety through prompt charting of accurate data. In this way the document provides the foundation for further decisions without delay. The integrity of the chart is not compromised when used in treatment decisions, in assigning costs in billing, and in continuous quality improvement reviews by supervisors.

What about the late entry window for the date/time stamp? Rather than institute a system that does not promote the values and virtues of best practice, the hospital might consider a standard that patients' charts are considered to be incomplete until one hour following the end of the shifts, thus recognizing that data entry does not supercede actual patient care. The standard removes individual discretion to self-determine the parameters of post-shift charting up to eight hours. It gives supervisors a consistent management approach and it does not withhold the document from review for billing.