Nursing Documentation: Court says charting only abnormal findings unacceptable - page 2

by NRSKarenRN 5,023 Views | 14 Comments Admin

Check out the October 2013 Legal Eagle Newsletter... Read More


  1. 0
    Charting by exemption is one thing ie side rails up, etc. but not charting vitals is not charting by exemption. Remember if you chart everything and one day you forgot to chart say side rails up even if they are up it will look like they were down that day. Charting by exemption means not having to document every little thing that goes on but what is different that day with the little things. You always will have to chart anything that can effect the outcome of care.
  2. 0
    Quote from jeckrn
    Charting by exemption is one thing ie side rails up, etc. but not charting vitals is not charting by exemption. Remember if you chart everything and one day you forgot to chart say side rails up even if they are up it will look like they were down that day. Charting by exemption means not having to document every little thing that goes on but what is different that day with the little things. You always will have to chart anything that can effect the outcome of care.
    I have heard this too. I have also heard that it is better to be consistent, not matter how you chart. so if you chart 'side rails up' then you have to chart that all the time, or else if someone falls and you don't chart 'side rails up' - that will be interpreted as the side rails were left down as jerkrn stated. Courts will pick up on inconsistencies.
  3. 0
    I think the main problem is that nurses failed to follow the physician's order of obtaining sats. Anytime a physician orders data to be collected it should be implied that it be documented. So unfortunate...
  4. 3
    It's not charting by exemption, it's charting by exception. Nobody is being exempted (excused) from anything; only exceptions (deviations) from normal or specified ranges/menu choices are charted. Agree these guys blew it.
    psu_213, NRSKarenRN, and Altra like this.
  5. 0
    I was just on a case for work and let me tell you, if myself and the other nurses had only charted by exception we would have been up that proverbial creek. Our charting was raked over the coals. We were all consistent in what we saw but slight differences in verbiage is what they went after. BE Consistent! And chart defensively, especially with electronic charting..it becomes very easy to click boxes and not explain what is abnormal. If there is an order make sure it is done, doesn't matter if the 4 people before you didn't so it. Always perform your own head to toe assessment, don't rely on the person before you.


Top