I often tell people that I was practicing nursing back in the days when dinosaurs roamed the Earth! We didn’t have computers then and we didn’t have charting by exception. We only had what we would write down in the paper chart medical record.
While progress in technology has since made documentation so much easier, these advances may not always be in the nurse’s best interest. When all you need to do is check the boxes to record how the patient is doing, it’s hard to make sure that A + B = C.
Just this week I was looking at a case where the patient had profound dehydration with elevated sodium and the nurse is documenting “moist, mucous membranes and normal skin turgor.”
How can this be?
Before you go checking off any of those boxes, think through the patient’s situation and diagnoses to make sure that what you are documenting adds up. If it doesn’t, then write a narrative note to explain why.
Although charting by exception can save time, blindly checking boxes is neither your or the patient’s best interest. Like any form of documentation, your judgment and common sense is what’s important. Just ask yourself, “Does my documentation tell the full story of the patient’s condition, professional assessment and care?”
Just checking a box, say, about wound drainage being bloody leaves out specific information such as the color, consistency and quantity of the drainage. When you put a pain assessment of “9/10,” you need to document the location, intensity, duration, aggravating and relieving factors in your pain assessment.
I often see nurses who will copy the page from one day to the next. This is a DANGEROUS practice! When you put pen to paper, you really have to think through the patient’s issues and document what you see, smell, touch and hear.
When you go to chart, it is best to think through the patient’s situation and make sure that all your assessments are appropriate rather than just a matter of checking a box. It could save your license and keep you from a malpractice matter. I would love to hear your thoughts and how you think through your charting in the comments below.
Nicole Pugh says
More nurses need to read this article! With the implementation of electronic medical records, nurses were taught to chart by exception and discouraged from entering narrative notes. We have to find the right balance.
Juanita Bonner Stemen says
I applaud you for tackling this issue. In my job I inspect healthcare facilities and often hear “we chart by exception” as a reason for missing documentation. This happens when based on the Patient’s outcome there was clearly something going on.
When given an opportunity to speak to nurses I remind them of the hard work they put into getting their license. I encourage them to protect that license by documenting accurate information and not leaving the residents condition open to interpretation.
Jeanne St. Pierre says
Thanks for your comments, Lorie.
We are currently discussing adding “baseline” as an option on our assessment flowsheet (for pts whose baseline is abnormal) so we don’t have to write it in all the time, vs charting “within defined limits” or “exception to WDL,” which in turn generated discussion on how ‘baseline’ would be defined.
Has this come up in your world and do you have any suggestions?
Thank you.