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Discussion

Charting by exception...

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!

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    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.

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    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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