Charting by Exception: A Cost-effective, Quality Approach
A time-efficient and cost-effective method of documentation of nursing care through a system of charting by exception (the documentation of abnormal or significant findings using a standard normal base) is described in this book. The method eliminates time-consuming documentation of normal findings and repetitious information, allowing the nurse to spend less time at the desk and more time caring for patients.
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The Process of Planning Patient Care
Case Studies of the Charting
The Impact of Charting By Exception on Cost
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24 HOURS 48 HOURS abnormal and/or appropriate asterisk bedside category box Charting By Exception check mark Chemotherapy CICU completed Day Surgery Record direct patient dysuria edema Emergency Department evaluation Figure Foley catheter Graphic Record HOURS X 24 housewide identified incidental order init Luke's Hospital Luke's Hospital Milwaukee Medical monitoring needs normal Nurs nurse shall ensure nurse shall utilize nurse's nursing care plan Nursing Data Base Nursing Diagnoses List nursing documentation nursing interventions nursing orders Nursing Practice nursing process Nursing/Physician Order Flow NURSING/PHYSICIAN ORDER FLOWSHEET Order Flow Sheet paresthesia patient and significant patient care plan patient day Patient Discharge Note Patient Teaching Record patterns physician Policies and Procedures post-operative PRE-OP PRIMARY NURSE problems PROCESS STANDARD protocol Q 4 HOURS RESPIRATORY ASSESSMENT reverse side shift report Signature of R.N. significant findings SOAP Note specific Standards of Nursing STRUCTURE STANDARD Surgical tion urine utilize these Policies vital signs Wisconsin