Charting by Exception = Redundancy

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Specializes in CCU/ER.

Okay, so my evaluation this year said I need to improve my charting. Last yr my evaluation (by a different RN Mgr) said my charting was excellent. When I questioned the difference I was told I needed to do the charting by exception AND type a full assessment in freehand style.

The more we use the computer for olnine charting, the more redundant and repetitive and time consuming it becomes. It takes me 15 minutes to chart a 5 minute assessment. Now, if I chart their way, my next eval will say I take to long to turn over my pts.

Anyone else experiencing this? We were taught that charting by exception would be a better CYA system. Now they say we have to do both. :angryfire

How irritating is this!!!?!?!?!?!?!!!!????

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Specializes in Community Health Nurse.

I prefer not to do the computer charting for those very reasons. It's very time consuming and takes the nurses away from their patients even moreso than we already are. Double charting is totally unnecessary. :rolleyes:

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anybody else remember how great flow sheets were? I loved charting with them. Charting by exception was the rule on the nurses noted because you had covered the basics on the flow sheet.

Would someone tell me why they can have a computer program for everything else, why not a good, to the point flow sheet ? Unit specific in some areas, but general enough to get the job done and quickly so we can take care of patients.

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Specializes in Med-Surg.

I think whoever does your evaluation needs to reconsider. I agree, it's redundant.

We have computer charting here, and don't have to double chart. A few people do double chart, writing things like "lungs are clear, patient is A&O x 3" while at the same time checking off normal assessments in the computer. Redundant and repetitive charting isn't going to impress a lawyer or jury IMO, so I don't do it.

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Charting, when done by exception, should be just that. You should not be charting a separate assessment in longhand. Your administration needs to get it together with the legal dept and get soemthing worked out. If you are having to do a full assessment in longhand then you are defeating the entire purpose of the way that you are charting..............

Computer charting, when set up proerly, can be absolutely wonderful....Snd I have been using it since back in the days of the pilot programs, well over 10 years ago.

It can be done............. :)

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Ack! I just came out of a hospital using computer charding (are we allowed to specify the name of the system) anyway, we are now implementing the same system at my new workplace :smackingf . It is horrible! It would be so much better if our vital sign machines or our monitors (I work OB) were integrated with the system, but since they are not we spend so much time looking at the screen and so much less time with our patients. If we do not, we spend hours after our shift trying to chart while all the docs are looking for information that they can not find since it is not charted!!! :crying2:

Each hospital customizes differently, so hopefully this one I am at now will be a little better. With this system at least, it is almost impossible not to double or even triple chart because it shows up on so many different screens asking for the same type of information. If the information is left out on any given screen it does not show up in the right place to be viewed and it looks like you did not do it!!! :angryfire

Anyway, this is no help, but I think that a nurse who knows programming should write the software (along with the legal department) to take out all of the redundancies and streamline it. Sorry for the vent!

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Specializes in CCU/ER.

Vent away, Littlewonder! I hear you and I totally agree!!!

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