I'm the author of the two books on Charting By Exception and I want to welcome you all to Charting by Exception Advice. I've been consulting for over twenty years on how to implement Charting by Exception correctly, and offering expert witness testimony on cases using "charting by exception" as a defense for nursing documentation. I'll be writing periodically on issues related to Charting by Exception, and I'll answer your questions.
Just to be sure that everyone understands the basics of CBE, there are 3 key principles:
- There are baseline definitions of norms, so when you use a checkmark, asterisk, arrow, or computer keystroke, you know what you are referring to. These are either written in your documentation policy or are listed as reference text on your computerized documentation system so that you can always speak to what you meant when you used the symbol. The * symbol actually means that there WAS an exception to the norm and you're SUPPOSED to write a narrative note that describes the deviation from norm. CBE guidelines clearly state that you should document the changes in the patient's condition using narrative notes or selections from computerized pick-lists with additional remarks made in narrative form in the "comments section." Using CBE does not exonerate you from documenting teaching and changes in the patient's condition. Make sure that these issues are addressed according to your documentation policy.
- When the nurse charts the accountability timeframes, he/she is also indicating that all standards and protocols were followed. Again, the documentation policy needs to state this. I've been an expert witness on legal cases where the documentation policy was inadequate because policy designers didn't really read the CBE books, they just claimed that they didn't chart anything because nothing was unusual and they thought this was Charting By Exception (WRONG!) or they adapted an "idea that they heard about" (usually the use of symbols without the defined norms specified) and that caused problems in their institution. Do it right and it always works!
- Chart as you go! Documentation is always more exact, complete, and accurate if the nurse does "real-time" charting. If you're working in an electronic charting system, make sure that the date/time on the data you're entering is the time you want it to be! Some systems have defaults set to "today" and "now", yet the nurse may be recording a finding that happened in the past. The nurse has to be diligent to assure that his/her documentation reflects real-time charting, either by doing it as they go, or by staying vigilant and adjusting the dates and times to the appropriate ones.
I'd like to make one additional comment. In our second book, we wrote about the 6 key features of exception-based charting systems. The one that I consistently see missed is the need to have ongoing auditing done and remedial education or performance evaluations that include adherence to documentation policies.
You can't just throw out forms with symbols and no defined norms, you can't expect nurses to know that they gave care according to standards unless you define for them where those standards are documented and what they include and you can't expect nurses to remember details of complex care sequences of events if you don't provide them with the necessary tools to "chart as you go" like either bedside paper charts or computers on wheels, bedside computers, or computer tablets.
Be sure all of the above are provided. Then, audit regularly. There are lots of nurses who are using good CBE systems across the country. Our second book actually quantifies that. But my experience also notes that there are always a small minority that don't do it right, don't bother to learn how to do it right, and then complain that the "system doesn't work." Make sure your system is sound, and then audit and coach these laggards to high performance. You'll like the results because the clinical record will truly reflect good nursing care and begin to highlight where nursing performance can improve to achieve excellent patient outcomes. And isn't that why we got into this profession in the first place?
