Where I work, we chart by exception. We have a shift assessment that is entered in the computer, each body system can by wnl, or abnormals checked. If you chart wnl, it shows you what you mean ex. under neuro wnl, a/ox3, perla, etc. I then do a progress note in the computer that supplements my shift assessment because some things are easier to narrate ex. wound descriptions, while there are multiple screens that I could go through checking, I just think it is easier to describe with words. I do chart by exception with most other things. I often chart things like an iv site as unremarkable. I was taught that that means it isn't red, painful, swollen, outdtd, cold to touch etc. and and it alleviates the chance of you accidently omitting one of those words. I work on a med surg unit, sometimes I have 10 patients to start and with discharges and admissions by the end of twelve hours I have taken care of 12-14 patients or more. I think that if I wasn't able to chart by exception I would sleep over some nights to finish. I do progress notes throughout the day for anything that happens, patient going off floor for test, patient complaints, calls/discussions with md's, discussions/teaching with patients & families, etc. If there is nothing to chart in 12 hours except their assessment (not likely), I would chart a note halfway through the shift that the patients assessment is unchanged. There is alot of information regarding charting by exception, but if you can imagine 4 years down the road when you may need to refer to your notes and explain them to an attorney, chart with that in mind. In other words I would rather have someone ask me, what I meant by "unremarkable", as opposed to someone ask me since I charted that an iv site was not red, not swollen, not warm or cold to touch, not outdtd, did I ask if it was painful....and then have to answer of course I did, because I always do. We all know if we didn't chart it, we didn't do it. I think many may say that you can't chart worrying about a lawsuit, but having seen people go through it, I say it is the only way to chart.