Charting by exception

[icunurse1955]

I need help. I am a Director of a combined ICU/Telemetry unit. We now do all nursing documentation in the computer. My nurses do so much charting that they seem to be married to those computers and I am looking for a way to cut down on some of the documentation. Our ICU patients get a full head to toe assessment at least every 4 hours. This assessment is documented every 4 hours, normals as well as abnormals. Does anyone out there just chart the full head to toe assessment and then just chart on abnormals for the remainder of the shift? I would be very interested in looking at your patient assessments and documentations policies if anyone is willing to share those with me. You can either e-mail them to [email protected] or fax them to 1-815-432-7809 and address to Peg. Thanks

[TigerGalLE, BSN, RN]

Well I don't have anything to fax you. But our computer documentation is divided into systems. You chart on each system and there is a selection for WNL. If their skin is warm, dry, intact ect.. you just chart WNL. If they are there with pneumonia but they are neurologically intact you just chart WNL under neuro. Also after you have done your initial head to toe assessment, the next time you chart you can chart, No change in assessment, or changes documented below. So if they are wheezing this evening and they weren't this morning, then you just have to go chart on the respiratory section and it leaves your other documentation the same.

It really helps save time.

Hope this helps

Tiger

[kathy313]

When I worked CCU/Stepdown, we had to do the full assessment in CCU every four, but in the Stepdown we did the full at the start of our shift and then chart any abnormalities. If I was doing twelve hours, I had to do the full again (@ eight hours).

If y'all just started computer charting it can take a little longer, some people just aren't used to it or they are resistant to change. It actually is much quicker, the information is right there and most of all it's legible. We used Meditech, then the hospital started emar and it was hard for some people to catch on, just takes some time. Once management starts c/o about overtime, the pace will pick up!

[Up2nogood RN, RN]

Since I'm not in cc we only chart by exception Q shift unless there's a change so it doesn't take long. We do have the ability to copy the previous assessment and then can make changes which also cuts down on charting time.