Charting by exception

  1. What do you all think of the charting by exception? Is it REALY going to hold up in court. I just can't get the knack of a blank assessment paper with just the time on it. I still chart on it. I may be crazy. This post can not possibly cause any arguements can it?
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  2. 16 Comments

  3. by   Altra
    That's the way it's done at the two hospitals where I've had clinicals so far. It seems to be rare that the nurse doesn't write anything, even if there are no alterations in any body system - they still tend to write at least something like "pt. A&O x 3, sitting in chair, no c/o pain" etc.
  4. by   RN Rotten Nurse
    the less you chart, the less you have to answer to..........
  5. by   panda_181
    Well...I agree that there are few that really don't chart anything, but that's what the flow sheets are for...you putting your initial or however it is at your hospital is acknowledging that you have assessed that part of your patient. That should hold you up in court as strongly as you writing the same thing...your name is there, so you're responsible...and it saves ink!

    Amanda
  6. by   suzanne4
    Quote from RN Rotten Nurse
    the less you chart, the less you have to answer to..........
    Hopefully you haven't been a nurse too long and will open your eyes. Even if you are charting by exception, you have someplace that you have either noted that everything was unchanged, which means that you did your assessment and found nothing wrong...........or you made an actual note about the changes. Remember the old phrase, if it isn't charted, it isn't considered done. And if nothing is there, what can you remember later if the chart ever does go to court? I hope that you rethink your strategy. :uhoh21:

    If the patient had no problems, why would they be in the hospital?
  7. by   SharonH, RN
    I have been charting by exception for at least the past 12 years. It is truly hard to get used to because many nurses feel they have to write something. However, I refuse to write over and over "A&O, SR up, resp. nonlabored, etc". I do my initial assessment and make note on the flow sheet and after that, I truly do not write unless something changes or I'm closing out. So far, so good (fingers crossed).
  8. by   sharann
    Quote from SharonMH31
    I have been charting by exception for at least the past 12 years. It is truly hard to get used to because many nurses feel they have to write something. However, I refuse to write over and over "A&O, SR up, resp. nonlabored, etc". I do my initial assessment and make note on the flow sheet and after that, I truly do not write unless something changes or I'm closing out. So far, so good (fingers crossed).
    Thanks. I will try to write less(since its redundant to write A/OX3 on the A/OX3 line). I do utilize the summary part on the back for a full head to toe narrative. Probably this is ridiculous of me, unless there is a change of S/S.
  9. by   Gldngrl
    What about situations where one nurse documents his/her assessment (whether by exception or narrative charting) and the next shifts circles "unchanged" and signs name?...you've done the assessment, but are relying in part on what the previous shift charted...esp if the previous shift charting is incomplete...
  10. by   Tweety
    I think it does hold up in court. Apparently though our hospital lawyer says he has a hard time convincing a jury of average joe blows what charting by exception means.

    I love charting by exception. The less paperwork the better.
  11. by   PMHNP10
    And keep in mind...if your hospital has the policy of charting by exception, and you don't you leave yourself open to problems in a court of law...not following the protocol, guidelines, etc.
    My previous job was charting by exception, but yet throughout the assessment, they had many areas where you could initial a box and it says something like relaxed, or appropriate affect or stable and coordinated gait--I thought these were good things, not exceptions .
    Also my NM told me I had to put a note at the end of the shift saying whatever. NUh Uh not if all is ok. Pt asleep, no signs of distress; no change since previous assessment, etc. is not an exception.
  12. by   fergus51
    I love this method of charting. We also do a flow sheet and no narrative unless you need to explain some sort of variant. There are still nurses in the unit who do a full narrative assessment, but they are the exception.
  13. by   Sadie04
    I love charting by exception. Why write the same thing over and over if nothing has changed?
  14. by   Rocknurse
    It may be quicker but I believe it still leaves you open to trouble. A friend of mine was accused of neglect when the change of shift nurse came on. She said my friend had left the NGT hanging out, and the feed was going into the patients lungs. Thankfully, my friend had documented at 7am that she had checked the tube and it was in correct placement and that the lungs were clear. If she had charted by exception she could have been written up. Of course this other nurse really shot herself in the foot when it was discovered that she had signed that she had given all the morning meds...via the NGT!

    I will still continue to document the things I have done. I won't necessarily say "patient sleeping, no change" but I will say things like "NGT checked and correct" or "pressure areas checked while turning patient - intact". Anything that covers my butt is a good thing.

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