Charting by exclusion

NurseguyFL · Mar 23, 2007

For each systems assessment, there is usually a check box that you will click on if the assessement findings are within normal parameters. There's a paragraph next to the check box that defines what the 'normal parameters' are. So, as long as the patient fits whatever is described in the language, then you would check the box and not write anything else.

Depending on what type of charting system you are using, there may be either a list of possible alterations that you can choose from and/or a text box that you can free-text your nursing notes into if the assessment findings are not within normal parameters. Some charting systems will pop up a list of nursing diagnoses to choose from, depending on whatever alterations you click on, then you can choose from a readymade list of interventions or type in your own stuff.

There's really nothing more to it than that.

Daytonite, BSN, RN · Mar 23, 2007

i don't know that you are going to get any links to anything for this. most facilities create their own charting forms for this. they have a committee of some sort that puts their heads together to put a charting form together that they can all agree on. they send it to a printer who formats and prints it for them. it then becomes "proprietary", or owned, by that facility and they generally won't usually share them with others. the best you can do is grab a blank one to take home and study when you are in a facility for your clinicals that use these.

suffice it to say, that the theory behind this is that you begin by assuming that each patient has a normal physical assessment. this means that you need to know what a normal assessment for each of the 11 body systems is. what becomes the "exception" and gets charted is what "isn't normal". probably the best way to familiarize yourself with what is normal is to get a nice physical assessment reference book. there are a couple on the market that you can get for a reasonable price without having to shell out for textbook. or, you can go to this sticky thread on this very forum: https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html where you will find a number of weblinks to sites on physical assessment. most nursing students find that either their nursing program provides them with some sort of assessment form to use with their patients, or they end up having to create their own to use in the clinical area. it is something that will be a subject of your attention from time to time during your nursing career. carpenito and doenges include assessment forms in their nursing care plan books. some of the nursing textbooks have assessment forms on their online companion websites.

the idea with charting by exception is that you only chart abnormal things, not normal stuff. when reading nursing notes under this system, you "assume" that things went normally unless they have been charted otherwise. it's supposed to use less paper and save on the time healthcare personnel need to devote to charting.