Charting by exception

Well I don't have anything to fax you. But our computer documentation is divided into systems. You chart on each system and there is a selection for WNL. If their skin is warm, dry, intact ect.. you just chart WNL. If they are there with pneumonia but they are neurologically intact you just chart WNL under neuro. Also after you have done your initial head to toe assessment, the next time you chart you can chart, No change in assessment, or changes documented below. So if they are wheezing this evening and they weren't this morning, then you just have to go chart on the respiratory section and it leaves your other documentation the same.

It really helps save time.

Hope this helps

Tiger

When I worked CCU/Stepdown, we had to do the full assessment in CCU every four, but in the Stepdown we did the full at the start of our shift and then chart any abnormalities. If I was doing twelve hours, I had to do the full again (@ eight hours).

If y'all just started computer charting it can take a little longer, some people just aren't used to it or they are resistant to change. It actually is much quicker, the information is right there and most of all it's legible. We used Meditech, then the hospital started emar and it was hard for some people to catch on, just takes some time. Once management starts c/o about overtime, the pace will pick up!

Since I'm not in cc we only chart by exception Q shift unless there's a change so it doesn't take long. We do have the ability to copy the previous assessment and then can make changes which also cuts down on charting time.