Charting by exception...

  1. We have been given new daily flow sheets at work and are now supposed to "chart by exception." The entire assessment is supposed to be done by checks and we shouldn't need to write anything else in the notes unless "something happens." I am having a hard time with this and am not getting much help from my fellow nurses. Some of them simply write "assessment complete" and if nothing happened by the end of the shift, they then write "no acute changes, report given." That is fine with me, if it's okay to do, but is it??? The powers that be say they are getting us ready for computer charting where EVERYTHING will be checks. Then there are still some nurses who write every two hours, "pt sleeping, reading, no complaints" etc etc. While I love the thought of not charting much at all, I feel a little nervous because it looks like I haven't seen that pt all day long. What is acceptable? What do you all do?

    Laura

    PS I work on a med/surg unit in a small hospital where sometimes nothing DOES happen all day! With individual pts, I mean. Cause sometimes pts are admitted simply because the family needs a break!
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  2. 14 Comments

  3. by   hapeewendy
    I may be able to shed some light on this issue
    I work in a med/surg unit that uses
    CBE charting *charting by exception*
    and the check marks are based on set parameters for specific assessments IE - parameter 2 at our hospital is the CV parameter - if all of the criteria in a CV assessment are "normal" then you just put a check mark in the box , however if anything varies from the norm - i.e - increased pulse rate or BP or chest pain then an entry must be made.

    it does save time on charting, and overall it is an okay method of charting however if you feel a situation is worth charting on then do so.
    but honestly these days to chart every two hours that the patient is sleeping is silly...

    use your judgement , its your license
    but I do the auditing on my floor for charting by exception and see needless info written about daily

    of course , my motto is that if a patient is sour or whatnot ,Charting by exception goes out the window and narrative returns - just to make sure that you get everything that happens down.

    you will never "get in trouble" for charting too much
    but in a time where nurses are so overworked why chart things like "no c/o pain , or BP within normal range"?

    I do believe there needs to be modifications to this method of charting and I am working to include more things into the parameters

    cheers
  4. by   moonshadeau
    we have done charting by exception for about a year. It does have it's good points. But it also has its bad points. For example, there does seem to be the tendency to just follow behind with greater than signs without really reading it. I am one of the ones that tend to write a bit more and try to be a bit more through. Everyone needs to do it the same way or there is some problems. I do try to write at least something as a data entry on everybody at least once a shift. Charting by exception doesn't document teaching, MD update or care progressions in terms. You need to still document these things.
  5. by   hapeewendy
    in our facility charts are audited once a month
    by the floor auditors
    and notes are given to people who dont seem to be doing assessments of their own and just blindly follow what others have written....
    also if this pattern repeats, they must attend a CBE inservice where the importance of doing assessments is stressed etc

    as for the health teaching aspect, it must be charted and is charted at our facility, it comes under the (I) for nursing intervention on your nursing flowsheet, and of course changes in condition should consistantly be charted on, in the case of improving health status parameters are often discontinued as the patients need for evaluation of these parameters decreases
    as mentioned before, in the case of a patients declining health it is of course acceptable to chart in narrative form.
  6. by   dawngloves
    Do you write nurses progress notes in your charts? This could CYA.
    I worked a place that did this type of charting and I always wrote, "VSS, Continue to monitor"on the sheet, unless they were'nt stable of course.Then I'd write a narrative note in the chart.
    I would crack up when the previous nurses would check that a certain line was patent and it had been DC'd two days ago!
  7. by   hapeewendy
    personally I will never forget a story that was
    told to me by the head of the CBE at our hospital
    just to show you how mindless some people are.
    an original mistake was made, and for TWO DAYS
    people "arrowed" the entry - meaning nothing has
    changed - i.e. for example if a patient is edematous you could write extremities edematous elevate on pillows and monitor q shift- then the other nurses could arrow this entry meaning theyve done the same for the swollen legs etc

    ok the funny part comes in where it was so interesting to see that a patient had and I quote
    "traction insitu to left EYE" (meant to be leg oops) so mistakes happen, its understandable, but for 48 hours this poor patient was documented to have traction insitu to left EYE

    wow that musta hurt like an S.O.B.
  8. by   NurseRachet
    We also chart by exception. All units have 24-hour Flow Sheets that have multiple boxes to check. The critical care units check boxes and write out long hand the same stuff....can't change them. All other units are pretty good about charting only the exception, but we have found some that write basic info that is in the boxes. They just feel that they MUST write out info as well as checking boxes. When we went to electronic charting, they get away from doing this since the forms are all check boxes, or multiple select boxes. That really stopped this "long-hand" writing. Legally, if you write lots of stuff in a chart, it is more damaging then if you write very little - at least that is what we were told. The key is chart what is abnormal (and expound on that info) and what your intervention was. There are always going to be some nurses that fudge either way and chart non sense stuff or don't do a very good assessment and miss something. Everyone works under their own license...that is enough incentive for me to watch what I chart.
  9. by   NursNikNak
    just to show you how mindless some people are
    I know what you mean...my initials are "NA" and I have often found nurses who follow me will just "mindlessly" copy my initials, probably thinking that I mean "not applicable" (which I always write as "N/A" intentionally for the purpose of differentiation).
  10. by   CVSDnurse
    my first charting note is a quick head to toe general assesment of areas not covered clearly in the checks, the next 4 hour chart is often "no change from previous note" but never leave out anything abnormal that you notified a DR. about!
  11. by   Totone656
    We use a 72 hour flow sheet and are suppose to chart only the exceptions. Like many I do "CYA" when needed.
    The problem I have with our new flow sheet is the area used for nurse's notes is somewhat small, insead of being lined single is is lined double. Meaning, instead of it being College ruled it is just regular ruled. So when you need to "CYA" there is never enough space because the nurse before you has written her whole assessment and do they get an additional page? Well of course not, it isn't their job. <sigh>
    This flow sheet is suppose to help lessen the amount of time charting. I timed myself and found out it takes anywhere from 10-20 minutes to chart on each patient. So, with 15 patients a night I find myself the majority of the night making little checks and trying to write in the letters in the correct little boxes.
  12. by   el
    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.
  13. by   starhammock
    I have been charting by exception for about 10 years. Recently our charting changed, we are to cbe in the nurses notes and the chart to the care plan in the physician progress notes and talk about the patient progress toward the overall plan. I find it takes me at least 30 minutes to chart if there are no problems (patient progressing as should).

    I have to come up with an action plan on how to get my charting done sooner (it usually takes most of my shift now to assess and chart on 10 to 15 patients) because I take longer than anyone else to chart. I find most are not charting as we were told. I tried to email person in charge and was emailed exactly what to chart where.

    I work where team nursing is in place. I assess and give meds the med nurse cannot give or give pain meds to assist the med nurse. Our unit is a combo Peds and adult med-surg. We have had a lot of new people and can get 10 admits and discharges in a shift. I usually have my patients assessed within 4 hours, but getting it on paper with interruptions can take the rest of the shift.

    How can we improve this situation? Anyone with any suggestions?

    Thanks
  14. by   nurse_ange1
    Quote from NursNikNak
    I know what you mean...my initials are "NA" and I have often found nurses who follow me will just "mindlessly" copy my initials, probably thinking that I mean "not applicable" (which I always write as "N/A" intentionally for the purpose of differentiation).
    Nice to meet another NA... I had the problem of people thinking my initials meant "not applicable" when I was a teenager working in restaurant... I would initial it as NA on credit card slips and credit card companies complained that it looked like the "credit card number not applicable." So I starting writing my initals with my middle one as well... NLA... when ever I am actually writing "not applicable" I clearly write N/A and not my cursive NLA.

    Our hospital also has charting by exception, our flow sheets cover 48 hours. As a new grad I always try to make my own assessments before even reviewing said flow sheet, and I document what I see instead of just carrying on the same information as some people tend to do (Anyone else have those that complete all their charting for 12 hrs in the first 3...funny how that happens???). Whenever someone is outside of the normal range, unless ongoing known issue, I chart in the NN. And of course in a more emergant situation I go full narrative. It was a bit weird to get used to because of all of the abreviations, but after a few months it has become second nature.

    If I truly have a "nothing happened" day with a patient, then I don't write anything in the chart and just complete the CBE checkboxes to reflect this information.

    Also, our flow sheets have boxes for amt of teaching and the topic of teaching is documented on the care plan (i.e. ileo--- low residue diet booklet given and reviewed, pt comprehension acceptable).
    Last edit by nurse_ange1 on Jan 3, '06

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