Charting by exception

Originally posted by Deblnc

I'd like to hear some of your experiences with charting by exception. Have you ever been questioned, interviewed, deposed about nursing care assumed to have been done because it was part of the care plan, but not documented separately in the nursing notes? Are you comfortable that this format supports that you have met the standard of care for your patients?

I've been nursing for 22 yrs and have recently dealt with that situation. It wasn't as concerning at the time because of the care being giving was done in the home in a one-on-one setting. The "assumed" duties done were more of a custodial care nature. True nursing procedures were always to be documented, even if they were "non-eventful", they were still procedures the patient could not have done on their own. Thus, relieving the concern.

I have been dispo'd several times and from those experiences I can tell you that "If it is not documented , It wasn't done.

It is nice to assume "if it is not documented it was not done." The truth is that you cannot document everthing. You do the best you can. For instance, you can document "patient denies pain". But the lawyer asks "did you ask the patient about the pain in his big toe?" You did not document therefore you did not do it. True cases paraphrased: the nurse documented that s/he reported the labs to the MD. The MD denied being notified about the particular ones in question. Nurse screwed. The nurse documented "MD notified by phone". The lawyer asks "so what did you speak to the MD about?" Who knows. Think about it.

Clinical pathways, coupled with charting by exception, reduce the chance of documentation errors. Lengthy notes are used only to record deviations from the expected clinical course, giving nurses more time to provide direct patient care, a potent liability prevention measure.

We chart by exception where I work.