pediatric assessment: whole or by exception

[Pediatricjo]

The question has come on our unit what is proper: a documented full assessment or an assessment charted by exception. Currently we document a full assessment every shift. One of our nurses floated to another adult unit and they are charting their assessment by exception, except the initial assessment.

[NicuGal, MSN, RN]

Depends on the policy. We do one full assessment once a shift and then the others are by exception.

[brithoover]

Full assessment

[blondy2061h, MSN, RN]

I used to get floated to peds all the time. I always had teenagers but I did my usual full assessment- heart, lungs, bowel sounds, eyes, mouth, pulses, IV sites, any wounds.

[hiddencatRN, BSN, RN]

We chart by exception plus any pertinent normals/negatives.

[anon456, BSN, RN]

We do full head to to assessments every 4 hours. We have to put either WDL or state what is an exception on every body part and system, to show that we looked at them in all those ways. It takes a long, long time to chart but it's worth it to cover yourself legally. We have 3 complex patients or 4 generic patients.

[KelRN215, BSN, RN]

Full assessment once/shift. Anything normal could be charted as "appropriate for age" or "within normal limits" or whatever.

[~PedsRN~, BSN, RN]

I perform a full assessment, but I chart by exception. If I chart WNL, that's the same thing as charting breath sounds clear bilaterally, etc.

[Pediatricjo]

Our policy states "All patients will have a complete assesment done at the beginning of every shift; the nurse will document any changes from the baseline assessment (admission). Assessment of body systems that have not changed will not need to be documemnted as unchanged." Our pediatric policy is not as clear. We have EMR so it is easy enough to click a box for normals. I was just wondering what standards for Pedi assessment were elsewhere.