Charting by Exception

I'm not sure where you're going with this, but it sounds to me like you would rather stay witht the old fashioned narrative note. Everyone has different styles of charting, which can be a problem. If the nurse before you documents a full head to toe assessmet, with every assessment finding noted, and you don't, how does that look. You know that old cliche saying about documentation... Well if that is the case, everyone's note would be a novel. Sure, every unit is different. But on a floor, are you really going to mention every finding (positive or negative) on every patient, every time you chart? With a form, you can't miss it. God forbid I forgot to write 'abdomen soft, non-distended' in my note (because it really isn't applicable to the patient at this time), and on the next shift, her belly blows up? At least on the form, under GI, there is a check off that says "Abdomen soft...". In this case, only an abnormal finding needs a narrative note. Call me lazy if you will, but I think this is an easier, more practical way of charting.

What happens 7-10 years later when the nurse is called to testify in court? Here's what happens: The plantiff atty will use your notes, in whatever format, to attempt to discredit you and support his theory that the care you gave was below the standard of care. I don't think it matters if you use 'exception' charting but what does matter is consistency, accuracy and completeness. If the patient is really ill, you should have additional entries detailing what is being done and when the doctor/supervisor are notified of changing condition/acuity. In other words, it isn't the method (or format) that is the problem. Failing to advocate for the patient and initiating the chain of command are the most frequent arguments for nurse (and therefore, hospital) liability. As we have often heard, 'if its not charted, it wasn't done' is not altogether true. But the more detail the better, especially if you have a patient who takes alot of time and/or deteriorates on you. Patients go sour sometimes and how you react and document can make a big difference in your liability. You might also collect chart samples from other hospitals similar in size and location and tailor your forms to your insititution. I might also run a literature search and see what the currently available research has to say. Good Luck.

Our facility is currently revamping a lot of things. Charting is one of them. I've been selected to review the negative aspect of charting by exception. I've used it in other facilities and have to admit I'm pretty opposed. I've seen nurses simply check Within Determined Limits without comparing to care plans or even really looking at the patient in depth. I understand this is due to high patient loads, etc. But it seems staff gets desensitized by using a form rather than having to think about what they're assessing. I've checked threads and haven't seen a lot of postings on this subject.

One of my other concerns is that while I can look at the chart and recall the patient for a while, what happens in a civil suit 7 or 10 years later, when nursing is called in to testify in court.