What standard is most common for nursing assessments?

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Charting by exception, met/not met, or free text?

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Are you asking about student/teaching assessments or real life assessments?

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Real life assessments in an acute care setting

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Acute care everything is charted.

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CBE used to be the most common practice due to time constraints, however due to the increasingly litigious healthcare work environment, met/not met is now the direction that is being advised and taught to current students. Faculty are universal in the opinion that you are responsible for protecting your own license and this is the best way to ensure you can stand by your actions. Essentially if it's not written down then it didn't happen. Lots more writing... but a lot less ambiguity if the chart has to be scrutinized by a lovely lawyer :devil:

HTH

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CBE used to be the most common practice due to time constraints, however due to the increasingly litigious healthcare work environment, met/not met is now the direction that is being advised and taught to current students. Faculty are universal in the opinion that you are responsible for protecting your own license and this is the best way to ensure you can stand by your actions. Essentially if it's not written down then it didn't happen. Lots more writing... but a lot less ambiguity if the chart has to be scrutinized by a lovely lawyer :devil:

HTH

It isn't lawyers. It's JCAHO.

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Specializes in ICU, ER, EP,.
It isn't lawyers. It's JCAHO.

Nah, Joint doesn't depose you for eight hours in a room of lawers and tear through each letter of the alphabet you've written.

I chart everything and duplicate nothing.

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It isn't lawyers. It's JCAHO.

I'd like to think that that was the case but everything we are being taught right now is a CYA exercise from a legal standpoint, not to adhere to any quality standard.

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