Ask a Practice Consultant: What does excellence in documentation mean?

Every Thursday we post an article that originally appeared in the print version of NurseLink. This one is from the 2016 Spring issue and has been edited to reflect current practice.

CHARTING BY EXCEPTION

Charting by exception can be a useful method to document if it is:

  • factual
  • accurate
  • complete
  • current
  • organized
  • compliant with all applicable standards and legislation

Charting by exception means documenting a client's usual findings and the care provided in a shorthand way based on predefined criteria for nursing assessments and interventions. The client’s baseline assessment must be documented, kept current and available in the client record. Subsequent documentation on the client’s health care status will then be any/all changes from this baseline assessment.

The care that you provided is based on the standard care that your client needs. Your initial indicates that the standards are met – that is, care was provided as usual and the client’s status was the same as his or her baseline assessment. Any exceptions to this are noted on the documentation form (e.g. 'IPN' for integrated program note beside your initial on the flowsheet) and then documented in the client's progress notes.

KEEPING YOUR TEAM INFORMED

Charting by exception can put a client at risk if you aren’t diligent in initialing care provided or documenting any changes in from the client’s current baseline assessments findings. If you do not record changes in a client’s health status, other members of the health-care team may assume that an assessment was done, the client’s health status hasn’t changed or that care was provided when it was not. This puts your client at risk as even subtle changes in status could have been addressed by adjusting a care plan. Proper documentation helps all members of the health-care team keep each other informed and lowers the risk of a negative client outcome.

ANSWERS IN LITERATURE

I’ve always said that I love to return to fundamental practice literature – re-read and reflect on those textbooks, journal articles and guidelines that I learned from early on in my career. I’ve found that returning to previously reviewed practice literature always leads me to new learning, insights and improved application in practice. I encourage you to return to these valuable resources or contact one of the practice consultations at the College at practice@crnm.mb.ca or 204-774-3477 ext. 301.

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