Nursing Documentation: Court says charting only abnormal findings unacceptable
- 3Oct 10, '13 by GrnTeaI 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?
- 1Oct 10, '13 by psu_213If 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.
- 3Oct 11, '13 by tokmomI'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.
- 2Oct 11, '13 by CapeCodMermaidI 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.
- 6Oct 11, '13 by woohThe 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.
- 1Oct 11, '13 by Altra GuideThat 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.