Nursing Documentation: Court says charting only abnormal findings unacceptable

[NRSKarenRN, BSN, RN]

Check out the October 2013 Legal Eagle Newsletter

[nurseprnRN, BSN, RN]

I always hated charting by exception even when I was a new grad and didn't know much. It seemed intuitively obvious that it left too many opportunities for missed communication. I likened it to the difference between having your significant other not say, "I hate you" every day versus saying "I love you" every day. If only one is allowed, which works better?

[MunoRN, RN]

There is no definition of "charting by exception" that allows for vitals to go undocumented, that is not charting by exception.

[psu_213, BSN, RN]

If I solely charted by exception, there would be some patient in the ER I would have nothing to chart!

I always chart pertinent negatives. For example, if a pt is their SOB, I would ask them if they had chest pain or if they have chest pains with deep breaths and, even if the answer was "no," I would chart this even though it is a 'normal' finding. I can't even imagine not charting VS, even if they are normal.

[Esme12, ASN, BSN, RN]

I knew that was coming....I called that years ago. I have never charted by exception.

[tokmom, BSN, RN]

I'm with Esme. I too never believed in it. Instead I chart like a judge and jury are sitting next to me. Our higher ups tell us that we only should chart by exception and to put information in the notes is a waste of time. My notes are very lengthy and will stay that way. Some nurses have no notes their entire shift. To me, that is opening one up for a huge lawsuit.

[CapeCodMermaid, RN]

I tell my nurses that their notes should tell the story of what went on with that particular resident on their shift. If nothing happened, there is no need to write a note. But, if something happened, they need to make sure their note is clear enough that someone without any knowledge of the resident could read it and know what went on that shift. I tell them not to waste their time writing 'pleasant, ate well.' Unless they are on a calorie count or were admitted for failure to thrive, eating well is not something to mention every shift. My nurses like to comment on bowel sounds in every note they write. Again...if the person was admitted for pneumonia and is moving their bowels, don't waste your time charting. Certainly they would document an O2 sat of 46%. They would also have called the doc long before that, would have started supplemental O2 and any thing else that needed to be done. And, of course, if the doc ordered a daily O2 sat, that would be documented abnormal or normal.

[wooh, BSN, RN]

The court did NOT find charting by exception unacceptable. The court found that the center hadn't proved that it was using a documentation by exception policy. There's a huge difference.

In fact most of the article doesn't really have anything to do with what the court actually found in that case.

And that bolded stuff in the middle made to look like a quote? Not ANYWHERE in the actual court opinion.

This newsletter is a VERY questionable source.

[PalmHarborMom]

Being a student nurse maybe I just do not understand.... How do you know what is abnormal for a patient if there is no documentation about normal findings? I'm surprised that anyone would risk their license but charting that way.

[Altra, BSN, RN]

That charting was ... just not intelligent. I understand that in LTC settings a full set of vitals including SpO2 may not be obtained every day, let alone every shift. But if there is a physician order specifically to obtain SpO2 daily ... what other evidence can be offered that the order was implemented if no O2 sat is documented? Duh.

[jeckrn, BSN, RN]

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.

[0.adamantite]

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.