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Discussion

Charting by exception dose any one do it out there ?

I am one of a small team of RN's at our Hospital doing a nursing redesign for our med-tech computer charting we are trying to make the hole H&P and daily Physical as well as the OB daily Physical. charting by exception. Dose any one out there have a model for such a thing would love to ask questions about or maybe even come to see how it works for you. Any help would be great thank you in advance.

Ranchand RN:balloons:

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we use opus and it's very easy. you just check a box . i don't know what company makes opus , but i am sure you can find out. good luck and let me know what you do.

The basic idea is you have a set of what is normal for each system. Check if it's normal or not. If it's normal, you're done (unless it's "normal" according to the standards but still something is a little "off.") If it's abnormal, then you go into more detail. Nurses that love to write hate it. "But how will they know this and this and this?" Because you said it when you checked "yes"!

Just pick a program for it. Meditech (as bad as people say it is, I never found it all that bad, it just depends on who personalized it for you.) Aspen. If you want written, I'm sure hospitals around you have samples they can send you.

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We have got the basic format down and we are using med-tech. what i am looking at is what is being used for the normals and how it is being applied to medical records. On things such as labor progression how dose the DR know where you are in the proses es if nothing has charted out of normal? I see that if you set the normal limits narrow it would work but how broad can you set them with out opening those charting up to law suite??

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