Nursing Documentation: Court says charting only abnormal findings unacceptable

Specialties Legal

Published

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...

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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.

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Specializes in NICU, PICU, PACU.

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.

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