Charting by exception: the legal risks.

There are numerous variations to charting by exception. Virtually every facility that uses such a system does it differently.

But the general rule is that only unusual or unexpected findings, or those outside the norm, are recorded. Charting by exception does not necessarily result in patient records that give an incomplete picture, but minimizing documentation is risky. Nurses’ notes with few explanations, little description of key findings, or no mention of periodic patient checks could be construed as negligence by a plaintiff’s attorney guided by the premise, not charted, not done.

A lack of detail could compromise patient safety as well. A patient’s medical record is expected to accurately reflect his current condition, and a chart that’s missing pertinent information could fail to alert other clinicians to potential problems or complications. Well-designed flow sheets are a key part of a good charting-by-exception system. But this form of documentation should also call for notes concerning any significant indicator of the patient’s condition or change in status, any subsequent interventions and the patient’s response.

Observations call for specific detail: Record the color, consistency and quantity of wound drainage—“about the size of a quarter,” for example— rather than noting only that the dressing was “very bloody.” Significant deficits such as lethargy or lack of response should be charted as well. If charting by exception is the rule at your facility, pay strict attention to the parameters and exactly what you’re expected to include in the patient record. If you’re still uncertain, discuss the issue with your supervisor or an administrator, and ask for a written charting policy.

Remember, though, that charting by exception cannot be reduced to a simple set of rules. Like any other form of documentation, it demands sound judgment and common sense in determining what’s in and what’s out. Your standard should be: Does this document tell the full story of the patient’s condition and of our professional assessment and care?

Frequently Asked Questions

You have questions. We have answers. (It's why we're here.)

What kinds of activities might trigger a disciplinary action by a licensing board or regulatory agency? 

The fact is anyone can file a complaint against you with the state board for any reason—even your own employer—and it doesn’t have to be solely connected to your professional duties. All complaints need to be taken seriously, no matter how trivial or unfounded they may appear. 

How does a shared limit policy work?

A shared limit policy is issued in the name of your professional business or company. The policy provides professional liability insurance coverage for the business entity named on the certificate of insurance and any of the employees of the business entity, provided they are a ratable profession within our program. Coverage is also provided for locum tenens professionals with whom the business entity has contracted for services the locum tenens performs for the business entity.

The business, and all eligible employees and sub-contractors you regularly employ, will be considered when determining your practice’s premium calculation and share the same coverage limits you select for the business.

We have a shared limit policy. Are employees covered if they practice outside our office?

The policy covers your employees outside the office as long as they are performing covered professional services on behalf of your business.

If your employees are moonlighting, either for pay or as a volunteer, they should carry an individual professional liability insurance policy to cover those services. Otherwise, they might not be covered for claims that arise out of these activities.

There are plenty more where those came from.

See more FAQs

NSO Learning Center

More insights from some of the best minds in nursing.

Abbreviations in Documentation: A shortcut to disaster for Nurses

Trying to save time by using abbreviations? Make sure that you aren't putting yourself or your patients in jeopardy.

Defensive Documentation: Steps Nurses Can Take to Improve Their Charting and Reduce Their Liability

Whether you are an experienced nurse or recent grad, documentation can be challenging. Here is some information that can assist with improving your charting and reducing liability risks:  

Documentation on trial: 9 ways to protect your agency.

In most states, a patient can wait several years to file a lawsuit and then it can take years before the suit goes to court.

Do's and Don'ts of Documentation

Good documentation can help nurses defend themselves in a malpractice lawsuit, and keep them out of court in the first place.