How do you chart?

BSN16 · Sep 25, 2016

Do you use epic? I use a different system that doesn't give WNL as an option so for cardio i will usually put absence of click rub or murmur, S1 and S2. Then go in and list NSR, a-fib whatever the case may be

loriangel14, RN · Sep 25, 2016

Yes I will chart WNL if the assessment is normal for that patient.

WKShadowNP, DNP, APRN · Sep 25, 2016

While their medical history has bearing in their care as it leads to understanding of their current problem and how to manage treatment, your assessment should indicate what exceptions in their homeostasis exists at that moment.

I have hypothyroidism managed with synthroid. Would I expect you do document my endocrine as abnormal because of it? My TSH is normal so the only reason to document any endocrine assessment is if I had any signs of thyrotoxicosis or storm or what have you.

I have no current gyn or g/u complaints and I had a hysterectomy years ago, so unless you had to document my LMP, there is no need to say my GYN is a problem.

I once had rubella and chicken pox (years apart), but my immunization status is up to date.

Those other factors go into a health history, not physical assessment.

SOAP:

Subjective: what patient states is the presenting problem/current complaint. Perhaps the history of that presenting ailment (e.g. Pt. reports three day history of sore throat and fever unrelieved by OTC remedies. T-max 101.2 not reduced by tylenol/motrin, last dose 2 hours ago.)

Objective: Pt. has a hoorifice, "hot-potato" voice

Assessment: Oro-pharynx is red, white exudate noted. Clear nasal drainage. (full assessment deferred for purposes of this post).

Plan: Administer antipyretics/analgesia as ordered.

CrazierThanYou · Sep 25, 2016

Thanks for your responses. I happen to agree! :)

CrazierThanYou · Sep 25, 2016

Do you use epic? I use a different system that doesn't give WNL as an option so for cardio i will usually put absence of click rub or murmur, S1 and S2. Then go in and list NSR, a-fib whatever the case may be

No, its CPSI. It actually gives the choices as YES or NO but for ease of explanation, I used WNL. Previously, I have used PowerChart and McKesson, both of which had WNL and the except option. Since that's how I was taught, I continue to chart like that with modifications for whatever the charting software is.

Sour Lemon · Sep 26, 2016

I'm curious about something. When I'm charting my assessments, I am thinking of what is going on with that patient at that time. I have noticed that many of my coworkers at my current hospital will chart that a patients cardio assessment is abnormal if they have a history of hypertension, etc. If the patient is in normal sinus rhythm and I hear nothing abnormal on auscultation, I will chart that their cardio status is within normal limits. The majority of my coworkers will choose NO and list the medical problems the patient has. Again, when charting my assessment, I am thinking of what's going on RIGHT THEN, not a heart attack twenty years ago if their current heart function is normal. Because, really, past medical history is also available in the chart already.
Also, say my patient is in controlled afib but nothing else is abnormal. In my charting, I will say the patient's cardio status is WNL EXCEPT for afib, irregular heart sounds. A coworker of mine says that is incorrect and I should choose NO. My reasoning for choosing WNL EXCEPT is because that says to me, and others reading my charting, that while the patient is in controlled afib, otherwise, all is well with his cardio status. Also, my first nursing job was with one of the top hospitals in the country and that's how our charting was set up; with the choices of WNL, WNL EXCEPT, and NO.
I have never had any negative commentary from any manager or anyone else on my charting and in fact, I have gotten praise on my charting in my current position. So, I am just curious about others' charting thoughts.
How do you chart?

I never include history in my assessment ...just the patient's current condition.

ScientistSalarian · Sep 26, 2016

An assessment is an evaluation of the patient's current condition, so I don't think it's appropriate to include history just as a matter of course.

Sidebar: I'm not a fan of the "WNL/WNL EXCEPT/NO" system. My hospital uses Cerner, so there's a "Systems Review" field at the top and a lot of nurses will, for example, choose "WNL" for HEENT and then leave that portion blank in the detailed assessment below. Quick, clean, easy - I get the appeal. But I attended a presentation from our hospital lawyer who made a really good case for ignoring the WNL stuff altogether and simply charting everything you assessed in the detailed assessment, system by system.

It takes longer, yes, but when you chart "WNL" you're attesting that everything encompassed in that "WNL" was a-ok. If part of the reference material for that section includes checking a patient's ears or throat and it's not something you routinely check unless indicated, you're opening yourself up to liability for charting a false assessment. I know not everyone agrees on this but it makes sense to me Â¯\_(ãƒ„)_/Â¯

WKShadowNP, DNP, APRN · Sep 26, 2016

An assessment is an evaluation of the patient's current condition, so I don't think it's appropriate to include history just as a matter of course.
Sidebar: I'm not a fan of the "WNL/WNL EXCEPT/NO" system. My hospital uses Cerner, so there's a "Systems Review" field at the top and a lot of nurses will, for example, choose "WNL" for HEENT and then leave that portion blank in the detailed assessment below. Quick, clean, easy - I get the appeal. But I attended a presentation from our hospital lawyer who made a really good case for ignoring the WNL stuff altogether and simply charting everything you assessed in the detailed assessment, system by system.
It takes longer, yes, but when you chart "WNL" you're attesting that everything encompassed in that "WNL" was a-ok. If part of the reference material for that section includes checking a patient's ears or throat and it's not something you routinely check unless indicated, you're opening yourself up to liability for charting a false assessment. I know not everyone agrees on this but it makes sense to me Â¯\_(ãƒ„)_/Â¯

Plus it is easy to get complacent and document things not done. I reviewed a chart once with a bilateral BKA had WNL pedal pulses.

Workitinurfava, BSN, RN · Sep 27, 2016

The assessment is based on the current situation with your patient. The patients history should already be in the system based on their admission, if not it can be added. However your focus is to chart on what you see happening as of your shift. Things change with the patients sometimes and that is what we are looking for. We want a stable patient at the end of the day, however we treat them according to what they need treatment for, like what they are dealing with at the current time. The medications follow the assessment and medical conditions.

akulahawkRN, ADN, RN, EMT-P · Sep 28, 2016

While I do make use of "WNL" in my charting, it's only if I have assessed that system and can therefore say that the system meets criteria for "WNL". Yes, it's fast and efficient from a charting perspective. However what I also do if there's something that's not considered "WNL" I will write check the "Other" box and write "Except as noted" or something to that effect. This way it's easy to understand that I assessed the system and found a specific abnormality and noted it with everything else being "WNL". The specific system I use is Cerner and I have used Epic in the past, both of which will allow me the option of using an "Other" box in addition to "WNL".

I'm also used to doing focused exams. I work in the ED so often we don't focus on body systems beyond the immediate problem. I have been doing patient assessments for about 20 years, for various purposes. I've written assessments using various charting methods. While it's efficient, I do NOT like doing CBE-style charting because if the patient is completely well and I cannot find anything wrong, a CBE-style assessment would look completely blank, as if I had never done an assessment. At work we're supposed to use CBE and, quite frankly, I refuse to do it so I chart something for every system. Now if only the computer had a checkbox to note "Focused Assessment" as it would make my life quite a bit easier. I could do (and chart) a problem-focused assessment and then later do a full assessment if necessary.

peachypurple · Sep 28, 2016

I have a preceptor who changes my charting every single time....

a lot of the patients on my unit use bipap at night or while they are sleeping, and switch over to nasal cannula when they're awake. We usually keep it on the patient until breakfast time. So at 7am when I go in to assess my patients, they're usually still on the bipap, so I chart that on their respiratory section with the settings and how they're tolerating it, etc. On orientation our preceptors look over our assessments and every single time this preceptor will change my respiratory section. This preceptor changes it over to document that the patient is on however many lifers NC. And every time I say "but they were on bipap at 7am" and the answer I get is "well now they're on 4L NC"

I feel like this is a bad practice. I'm going to document what I see at 7am when I do my first assessment. Then, I can make a note at 8:15 or whatever time they switch over..."patient switched from bipap to 4L NC, tolerating well, will continue to monitor blah blah blah"