I see a fair amount of activity on this blog from viewers this month. What questions are you trying to answer when you come here? Are you finding the answers with what is posted here? Are there any other questions that you'd like to ask? Let's start a dialogue.
Laura J. Burke, PhD, RN-BC, FAAN
I'm wondering if you have better protection in court if you don't chart by exception. I've been in nursing for 9 years and a nurse practitioner for 5 years. Every institution I've worked at has always charted by exception. Our manager in the position I'm in now just announced this morning that we will not longer be charting by exception and we need to write a note on every patient, every shift (I work nights.) If the pt is waiting for a coronary angiogram in the AM our note should read something like, "pt is stable & awaiting coronary angiogram in the AM." It it was signed out to us to f/u echo results we have to not only print the echo & put it in the chart & in the signout sheet, but we also have to write a note, "echo results back" and the add the pertinent findings even though the next day's daily note will contain all this information as well. Our manager's rationale for using this method is that it will protect us in court but I believe she is incorrect. If there is nothing to do for the patient she wants us to write, "pt is stable, continue current management." How will that protect anyone in court? It doesn't tell you anything! A patient doesn't go to court because they were stable! They go to court because there was an event - something happened - and of course, that would be documented with an event note. I believe you open yourself to more liability if you don't chart by exception!
ReplyDeleteI've sent an e-mail to our nursing education & research department to ask what our hospital policy is on charting/documentation because there is currently no policy available for staff through the intranet on this topic & I'm awaiting a reply.
As an expert on the subject, what do you think?
Rivka
Hi, Rivka,
ReplyDeleteIf your organization has a written policy that states that it uses Charting by Exception, and if that policy accurately describes a Charting by Exception system that we described it in our books, then it is important that you follow the policy as written. However, if your organization has a written policy that states that it uses Charting by Exception and that policy doesn't reference the CBE system that we described in our published books, articles, and letters to the editor, then your organization really doesn't have a Charting by Exception system.
I've been an expert witness on cases for both the defense and the plaintiff. The cases for the defense have gone very well when the organization followed the advice I put up in my first posting in 2011. They have policies describing CBE according to and referencing our books and articles, they train their staff systematically on the policies, they audit their staff's use of CBE regularly, and provide coaching for nurses who need additional reinforcement.
However, I've testified for several plaintiffs' cases where there is no explanation of what charting by exception is or how to do it in the documentation policy, nor is there training or auditing of documentation practices. Then, when a negative outcome occurs, the record is reviewed, and there are missing assessments, intervention documentation, physician notification of change in patient condition or outcome evaluation, and the organization claims "we tell our nurses to chart nothing because we chart by exception." That is not what charting by exception is!
Charting by Exception uses a system of clear definitions, standards, and policies to describe "within defined limits" findings AND abnormalities. The nurse is not excused from documenting WDL or significant findings. Both should reflect the patient's plan of care or changes in the patient's condition.
You ask specifically about writing a shift summary note, even if the patient's condition was as expected according to the plan. According to Charting by Exception: A Cost-Effective, Quality Approach (Burke & Murphy, 1988, p. 51-52), a progress note is written when:
* a change in condition is identified,
* an expected outcome is evaluated,
* a plan of care is initiated, resolved, or reinitiated
* the patient is being discharged and the plan of care at home or the next level of care is summarized.
If your organization has a policy that the expected outcomes of the patients' care plan need to be evaluated each shift, then writing a note each shift evaluating progress toward expected outcomes, even if it was "progressing toward stated outcomes, cardiac cath scheduled for A.M." would be appropriate. Just be sure that this is an organizational policy and that your manager is not telling you to deviate from the organizational policy because he/she is not supportive of a CBE policy.
The most difficult cases to explain are when the organizational policy states "use CBE," CBE is appropriately described in policy and in organizational training materials, and all staff use CBE appropriately. Then, one person doesn't follow the practice, and during that time, the patient's condition changes and the nurse doesn't practice according to best practice standards, nor does he/she document his/her practice appropriately. That is risky behavior!
Best advice...educate yourself about evidence-based practice, deliver quality care, and know and follow your documentation policies and procedures!
Laura J. Burke, PhD, RN-BC, FAAN
I would like to know if you plan to update your book(s) and republish them with the latest and greatest data . . . I have found one old version of your first book to buy but was interested in the second book but it is not available anywhere near me. There are so many questions about CBE--it might be time to revisit this and share. What are your thoughts on this?
ReplyDeleteHi, Cheryl, The other way to find the second book, besides looking on Amazon or other book resellers, is to request borrowing it from your local library. Even your city libraries have the ability to connect with university libraries and obtain out-of-publication copies. Or, you can email me personally at msljburke@gmail.com and I'll answer your questions directly. You say there are so many questions about CBE. What might they be?
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