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?