Full Assessment, exception charting - how do you do it?

  1. Thanks in advance for your replies and opinions!!

    We are going live with a new computer documentation system (Epic). We currently computer document mostly "by exception" with some narrative, depending on the nurse. With epic, we have an option for doing a full head to toe assessment and my manager feels this is necessary and we can use "WNL" as defined by the screen and hospital if a pt meets this criteria. My manager wants to take away WNL on the repiratory and cardiac screen (so even if the patient is WNL, I will still have to chart breath sounds clear, no murmur, ect) and are debating on what to do with other systems. The question is when do we do a full "head to toe" assessment? Technically when a patient (I work in pediatrics) comes in and they are alseep and we do not arouse them, their neuro/msk are not "WNL" or we won't know if they are until we wake them up. Do we defer charting until patient is ready to leave the pacu and they are mostly back to their baseline or do an "abnormal" assessment charting on arrival then do another documentation of assessment when pt is leaving the pacu? I hope this make sense. This is a big debate with my manager and I, since she is more "old school" and not very comfortable with charting by exception (less is more) and I want to decrease the amount of charting we do on our patients.

    Thank you so much!
  2. Visit kiminco profile page

    About kiminco

    Joined: Jun '06; Posts: 5
    Pediatric RN
    Specialty: 13 year(s) of experience in Pediatric PACU


  3. by   MauLoaPACUnurse
    Hi, Kiminco -

    We have been doing EMR charting for nearly a decade: first, with Karelink and now, EPIC. As far as documentation goes we follow the ASPAN standard/guideline for phase 1 and do head to toe assessment when the patient arrives in PACU, in hour, and when they leave PACU or meet Phase 1 discharge criteria. VS, airway, pain level, cardiac rhythm, and other vital physiological signs - these are done minimally every 15 mins. We do allow to click on "No change" if there are no changes from previous assessment. You can design your PACU documentation flowsheet so it doesn't take you forever to do this and still meet your hospital, ASPAN, Joint Commission, and other regulatory standards. The ASPAN Standards 2008-2010 has wealth of vital guidelines for perianesthesia nursing practice. If your department doesn't have one, I suggest that you ask your manager to order one for your unit. Their website: www.aspan.org

    Hope this helps ...