Charting by exception...

Nurses General Nursing

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We have been given new daily flow sheets at work and are now supposed to "chart by exception." The entire assessment is supposed to be done by checks and we shouldn't need to write anything else in the notes unless "something happens." I am having a hard time with this and am not getting much help from my fellow nurses. Some of them simply write "assessment complete" and if nothing happened by the end of the shift, they then write "no acute changes, report given." That is fine with me, if it's okay to do, but is it??? The powers that be say they are getting us ready for computer charting where EVERYTHING will be checks. Then there are still some nurses who write every two hours, "pt sleeping, reading, no complaints" etc etc. While I love the thought of not charting much at all, I feel a little nervous because it looks like I haven't seen that pt all day long. What is acceptable? What do you all do?

Laura

PS I work on a med/surg unit in a small hospital where sometimes nothing DOES happen all day! With individual pts, I mean. Cause sometimes pts are admitted simply because the family needs a break!

I know what you mean...my initials are "NA" and I have often found nurses who follow me will just "mindlessly" copy my initials, probably thinking that I mean "not applicable" (which I always write as "N/A" intentionally for the purpose of differentiation).

Nice to meet another NA... I had the problem of people thinking my initials meant "not applicable" when I was a teenager working in restaurant... I would initial it as NA on credit card slips and credit card companies complained that it looked like the "credit card number not applicable." So I starting writing my initals with my middle one as well... NLA... when ever I am actually writing "not applicable" I clearly write N/A and not my cursive NLA.

Our hospital also has charting by exception, our flow sheets cover 48 hours. As a new grad I always try to make my own assessments before even reviewing said flow sheet, and I document what I see instead of just carrying on the same information as some people tend to do (Anyone else have those that complete all their charting for 12 hrs in the first 3...funny how that happens???). Whenever someone is outside of the normal range, unless ongoing known issue, I chart in the NN. And of course in a more emergant situation I go full narrative. It was a bit weird to get used to because of all of the abreviations, but after a few months it has become second nature.

If I truly have a "nothing happened" day with a patient, then I don't write anything in the chart and just complete the CBE checkboxes to reflect this information.

Also, our flow sheets have boxes for amt of teaching and the topic of teaching is documented on the care plan (i.e. ileo--- low residue diet booklet given and reviewed, pt comprehension acceptable).

Specializes in post-op,oncology,nursery,med-surg..

when charting by excetion make sure you know the standard/ parametors to which you're charting to. ie. vital signs with in - / + 20% of 120/80, 60, 18 , 98.6 ect.

Specializes in Education, Acute, Med/Surg, Tele, etc.

I really like this system and frankly have used it for years. Our sheets have a small list of checks on the side, and room for charting the entire rest of the page. It also has an area above that has "no changes at _____" so that it shows the patient was checked every two hours.

I do tend to write more in the nursing notes because I am days and lots of things happen (med surge), I will write when the MD visits and say "see order sheet", and typically with my first entry I will put down "will continue to follow plan of care and narative PRN". Which helps show I will follow the care plan and if nothing happened all day...well that PRN statement covers that" That is my CYA!

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