Charting by exception

[sharann]

What do you all think of the charting by exception? Is it REALY going to hold up in court. I just can't get the knack of a blank assessment paper with just the time on it. I still chart on it. I may be crazy. This post can not possibly cause any arguements can it? :)

[Sadie04]

I love charting by exception. Why write the same thing over and over if nothing has changed?

[Rocknurse, MSN, APRN, NP]

It may be quicker but I believe it still leaves you open to trouble. A friend of mine was accused of neglect when the change of shift nurse came on. She said my friend had left the NGT hanging out, and the feed was going into the patients lungs. Thankfully, my friend had documented at 7am that she had checked the tube and it was in correct placement and that the lungs were clear. If she had charted by exception she could have been written up. Of course this other nurse really shot herself in the foot when it was discovered that she had signed that she had given all the morning meds...via the NGT!

I will still continue to document the things I have done. I won't necessarily say "patient sleeping, no change" but I will say things like "NGT checked and correct" or "pressure areas checked while turning patient - intact". Anything that covers my butt is a good thing.

[Tweety, BSN, RN]

A friend of mine was accused of neglect when the change of shift nurse came on. She said my friend had left the NGT hanging out, and the feed was going into the patients lungs. Thankfully, my friend had documented at 7am that she had checked the tube and it was in correct placement and that the lungs were clear. If she had charted by exception she could have been written up.

I don't quite understand that if she charted by exception why she would have been written up. Sounds like you have management that doesn't understand the charting system and is using it has a form of punishment.

We have protocols for NG tubes, if you check off you are following the protocol then you are signing off that you've checked placement and all is well.

I understand what you are saying though. I sometimes find myself doing the same.

[kwagner_51]

I am a student nurse and we also chart by exception. The hospital where we have clinicals, uses the computer to do the charting.

We have to chart V/S, ADLs, pain assessments, skin problems, etc. It seems to me that we are not really charting by exception. V/S are normal. If the order is to assist w/ bath then why put it in that you assisted with bath?

I do not like charting, using the computer. I would much rather write out exactly what I did, when I did it, and how I did it.

When we give meds, we have to scan the pt. ID bracelet and then scan the med. The drug cart stays in the Nurse's station and we haul a small table with a laptop computer on it into the pts. rooms.

Maybe I will like it better after I figure it out. It has been almost a year and I am still lost. Even the instructors have problems finding things on the durn pc. To me it is a PIA!

[ICU2RN]

My hospital also uses charting by exception but, apparently the floors/depts are not on one accord. My manager called me in today bcz the CNS stated I only had one narrative note for this past Sat. However, my interventions where we chart our asms and my adls and flacc pain scale was done q2hr. I explained this to her and reinterated charting by exception which is emphasized when you are hired and they teach you the system, and that I recently went to a seminar on nurse documenting held by a nurse who is now an attorney. My nurse manager understood and sd she would check our policy abt charting by exception. We also hv COWs (computers on wheels). Barcode scanning reduces errors and charting by exception mks you more efficient. The rest is just double charting if there is nort a section in my interventions that covers something I've done, for example calling the doctor, that's when I go to the narrative notes. What's funny is most nurses, drs, and mgmt do not tk the time to look at the narrative notes. I had given report to a nurse and she wasnt really listening. well, I also documented in the narrative notes abt somethg I hd told her. Later, she went to her shift charge nurse with an issue and didnt knw what to do. The morning shift charge called the night shift charge. When I come in for my shift it was a problem. I told them I gv her the info in report and more importantly, I charted what I hd done. My charge hd the nerve to say, "some people are too busy or overlook the narrative notes". Oh...ok...how is that my problem? no one took the time to research the notes, (no one checks bcz they think it's just a shift full of the same documented useless info of pt's staus every 2 hrs). Let's just say I was ******. They better be sooooo glad they didn't call me at home and woke me up abt it. I would recommend attending a legal charting and documentation seminar. I was given some great info.

[melsch]

Where I work we have charted by exception for over 15 years. We have tick sheets for the usual assessment and then a narritive area to write any unusual findings. When I was in acute care I felt more comfortable if I wrote something, so usually my charting for the shift would be A&O x3 denies pain lung sound clear vs normal IV patent BS present. No other complaints. I would also note any dressings etc. Where I am now in hospice we don't have full assessment tick sheets for every shift, just a pain/symptom tool if symptoms change. Documentation can be a bit spotty. I work nights so I don't wake my patients fir a full assessment and lots of times I just write asleep on all rounds. This seems to be adequate for our managers and I have actually been told that my charting is very good, of course I have been known to write a book if needed.