question about charing by exception

[uscstu4lfe]

so from what i've learned, we only chart any problems. charting anything else is a waste of time. honestly, sometimes there aren't any problems to chart about, so my narrative section would be like 1 line if i didn't chart the mojo (ie, respirations even and unlabored). even our supervisor said that we're charting too much useless crap. sometimes i think that if i'm not charing a moderate amount, then it looks like i'm lazy. what do you guys do??

[mama_d, BSN, RN]

I fill out the boxes on the flowsheet for the assessment...then if there's nothing out of the ordinary, narrative reads "Assessment per flowsheet. No acute distress noted. Pt resting comfortably in bed, encouraged to utilize call light for any needs." Subsequent narratives read "assessment unchanged." I used to chart a lot more on my narratives but found better ways to spend my time (like at the bedside).

[classicdame, MSN, EdD]

There has GOT to be a reason why that patient remains in the hospital. What is "routine" to you is still worth documenting. You need to indicate that you at least evaluated for changes in condition. For instance, if patient came in with respiratory problem, document sats after walking to bathroom, after eating or talking to visitors, describe whether or not compensatory muscles are being used, is pt on room air or not---- you may not need to write each item each time you enter the room, but indicate that you are continuing to evaluate and the patient is continuing to improve (or NOT!). Otherwise, how can you justify 24/7 nursing care? You are guarding your job!

[oneLoneNurse]

I do my four lines of narrative for every patient.

I chart by exception. I mean if something really happens, I write pages, BUT otherwise keep it to short and sweet and one entry for my 12 hours. Staff have come to know my four lines and have nicknamed them, "Kevin lines."

[grandee3]

We have the same charting, I usually chart what I see when I walk in the room for the room the first time.

We had a lot of discussion in an inservice about charting (got dinged by state)recently. My DON says we cannot chart Will continue to monitor. We must use monitoring in progress.

Our flowsheets are 6 pages long, it covers things, sometimes twice or three times and they were just revised. :bluecry1::bluecry1:

[grandee3]

I do my four lines of narrative for every patient.

I chart by exception. I mean if something really happens, I write pages, BUT otherwise keep it to short and sweet and one entry for my 12 hours. Staff have come to know my four lines and have nicknamed them, "Kevin lines."

Kevin, do you chart the same all the time when everything is alright. I used to do that and also changed it up a bit. Sometimes in LTAC things remain the same, even in the phy orders, all you see is chart checks on the whole page.

[RNKel, ASN, RN]

BUT otherwise keep it to short and sweet and one entry for my 12 hours.

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You only chart one entry on an entire 12 hour shift? Or am I misunderstanding?

[DoeRN]

We chart the same way. I try to keep it short and sweet but I am wordy by nature and just want to be careful. I am a new nurse so I am sure I will fall into a routine eventually. But the good thing is my preceptor said my charting is amazing!!

[caliotter3]

When I worked in LTC facilities we were not required to do narrative charting on anyone unless they were on alert charting for some reason, such as abnormal vital signs, symptoms of illness, receiving antibiotics, etc. Couldn't imagine pulling 80 charts and trying to figure out what to say if there were no changes.

[wooh, BSN, RN]

If everything is good, everything is good. If it's Within Normal Limits, no amount of charting is going to prove that they need care or don't need care. So chart that it's WNL, and go spend some time with them, or take the break that you otherwise won't get.:)