Charting by exception...

[FutureOBNurse2118]

I am a new nurse and the facility that I work at uses the McKesson program to do our charting and for those of you not familiar, we chart by exception. I love this type of charting because it cuts out alot of things but I am also concerned because it cuts out a lot. I am not sure how to know if I am charting enough?? Anyone else have this issue or have any advice?

[KittyLovinRN]

The hospital system I work for also charts by exception but because this is the only charting I've ever known it has been a bit easier. My two jobs have both been in critical care so I like to add a little more detail into my assessments because there's so much going on with the patients. For each body system (neuro, gi, gu, etc) we have comment sections where I like to give an outline of what's going on with the patient. Even if the patient is completely A&Ox3 I chart it even though it's not an abnormal finding. For instance for neuro I would write: Pt A&Ox3, mae, follows commands, denies pain, appropriate or for GI: Denies N/V/D, PEG intact, patent, infusing TF at goal per orders and tolerating well - or change it depending on your assessment of course but I find that writing notes at the bottom really helps to give a better understanding to what that specific pt has going on (plus the more details the better if you're ever called into court and expected to remember a patient from 5 years ago!) Hope this helps!