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Documentation of Assessments

Med-Surg   (243 Views | 1 Replies)
by Majoraty Majoraty (New) New

634 Profile Views; 6 Posts

I searched and couldn't find a topic covering my question.

Hi all - I'm a new grad, 4 months in. I work in adult inpatient surgery, so 98% surgical pts (mostly general, vascular, urology) and the occasional medical pt. I have asked a few RNs on my unit and there's differing opinions on what is required for assessment documentation. My preceptor was strictly chart by exception. Nothing normal should be charted in the box (we use Epic, so just WDL). Others write every single detail on every body system. I like charting by exception because it is easier to find what is wrong when looking at my documentation. If something changes, I do "UX - unchanged except" and document changes. I'm wondering if in addition to this I should chart the normals for what they came in for (I.e. if abd sx, chart active BS, soft, nondistended, etc). 

Do y'all tend to specifically write out the normals r/t what they came in for, purely chart by exception, or write out an entire full assessment? I want to be thorough but also clear and not waste time documenting an assessment for 30 minutes.

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kaylee. has 7 years experience and specializes in Stepdown . Telemetry.

302 Posts; 3,611 Profile Views

Yes I do a more thorough assessment of the body system(s) r/t why they are in. For the other systems I chart by exception.

What I have noticed is that SOME nurses will chart on all the things released into the flowsheet, whether relevant or not. (eg: sensory assessment using a feather haha). I am not sure if it’s laziness (rather than decipher the needed boxes they just chart everything) or they seriously are assessing these random obscure things. I think it’s the former. 

Point of my rambling: save yourself energy and skip the BS. To all the over charters out there, stop charting on assessments u didn't do! 

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