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!