Nursing Documentation: Court says charting only abnormal findings unacceptable - page 2
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Oct 14, '13 by nurseprnRNIt'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.
Apr 29, '14 by NicuGal, MSN, RNI 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.