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.