Have you ever reviewed health care documentation and found sections lacking? When questioned you were informed, we chart by exception, and felt you’re in a 1980s laundry detergent commercial stating “I can’t see the difference, can you see the difference?”
In some ways, charting by exception can resemble hardly documenting. However, charting by exception is concise and effective documentation, but only when used in tandem with:
- up-to-date client health assessments
- evidence-informed clinical protocols, and
- clear, predetermined criteria for assessments and interventions
If you are reviewing documentation where there is no comparison to a baseline, or to protocols, you may be able to see the difference by what is not documented.
Consider the following documentation:
09/08/20 – Daughter c/o constipation. Client concurs. Day 1 protocol——-A. Nurse RN
Besides asking whose constipation the daughter is complaining about, you may wonder what other symptoms and signs the client is experiencing, what day 1 means, and if the protocol is specific to this client’s health needs.
Should this client’s health care record contain an up-to-date health assessment completed earlier that day along with focused assessment of the client’s gastrointestinal system, this could be the baseline assessment upon which a focused assessment can be compared. If this same chart also contained the client’s current health care plan, regarding a protocol to follow for gastrointestinal complaints by the client that includes specific assessment data to trigger certain care actions, then a required care-plan is in place to apply for the client’s care.
Clear, concise, factual and timely documentation support you to maintain and build upon the Entry Level Competencies for Registered Nurses in Mantioba to document and report clearly, concisely, accurately, and in a timely manner. Then you will be on your way to continue meeting the Practice Expectations for RNs, including that RNs must:
- Demonstrate skill in written and/or electronic communication that promotes quality documentation and communication between team members
- Appropriately document the nursing care you provided:
- In a record specific to each client, and
- In the client’s record as the nursing care is provided or as soon as possible after the care is provided.
You can always review more CRNM information on documentation on our website.
You may also review the Canadian Nurses Protective Society’s website regarding documentation.
- The Canadian Nurses Protective Society. Quality Documentation: Your Best Defense
- CRNM Documentation
- CRNM Entry Level Competencies for Registered Nurses in Manitoba
- CRNM Practice Expectations for RNs