From the Guidelines
I strongly recommend charting by exception, as it provides a more comprehensive and safer approach to documentation from both a clinical and legal perspective. This method involves documenting only abnormal findings or changes in a patient's condition, rather than charting only when you see patients or issues. According to the American College of Physicians, good documentation is a fundamental component of high-quality care, and professional standards for high-quality computer-based clinical documentation should emphasize clarity, brevity, and attention to the needs of other readers, including patients 1.
When you chart by exception, you establish that you've assessed all relevant systems and parameters, with the understanding that anything not specifically noted as abnormal is within normal limits. This approach ensures better continuity of care as other healthcare providers can clearly see what's been assessed and what hasn't changed. It also provides better legal protection by demonstrating your thorough assessment and vigilance. Charting only when you see patients or issues might leave gaps in documentation that could be interpreted as gaps in care.
The use of macros and templates can be valuable in improving the completeness and efficiency of documentation, particularly where that documentation is primarily limited to standardized terminology, such as the review of systems and physical examination findings 1. Additionally, the electronic health record (EHR) should facilitate thoughtful review of previously documented clinical information, and ready review of prior relevant information, such as longitudinal history and care plans, may be valuable in improving the completeness of documentation as well as establishing context.
Key considerations for charting by exception include:
- Developing "chart etiquette" principles and policies based on a well-defined set of standards
- Including the patient's story in as much detail as is required to retell the story
- Using macros and templates appropriately to improve completeness and efficiency of documentation
- Facilitating thoughtful review of previously documented clinical information
- Supplementing pulled data with appropriately abstracted narrative content and referencing the source of the data.
By following these guidelines and charting by exception, you can ensure that your documentation is comprehensive, accurate, and provides better continuity of care for your patients.
From the Research
Charting by Exception or Only if Issues Arise
- Charting by exception is a method where healthcare professionals only document patient information that is abnormal or requires attention, rather than recording every detail of patient care 2.
- However, this approach may not be suitable in all situations, as it can lead to incomplete or inaccurate records, which can increase the risk of medical malpractice lawsuits 3.
- On the other hand, charting only when issues arise may not provide a comprehensive picture of patient care, and can make it difficult to track patient progress or identify potential problems early on.
- A more effective approach may be to chart regularly, including both normal and abnormal findings, to ensure that patient records are complete and accurate 3.
- This can help to reduce the risk of medical malpractice lawsuits, and improve patient outcomes by providing a clear and comprehensive record of patient care.
Importance of Accurate Charting
- Accurate and complete charting is essential for providing high-quality patient care, and can help to reduce the risk of medical errors and malpractice lawsuits 3.
- Charting can also help healthcare professionals to track patient progress, identify potential problems early on, and make informed decisions about patient care.
- In addition, accurate charting can help to improve communication between healthcare professionals, and ensure that patients receive consistent and coordinated care.
Best Practices for Charting
- Healthcare professionals should chart regularly, including both normal and abnormal findings, to ensure that patient records are complete and accurate 3.
- Charts should be clear, concise, and easy to understand, and should include all relevant information about patient care.
- Healthcare professionals should also review and update patient charts regularly, to ensure that they are accurate and up-to-date.
- By following these best practices, healthcare professionals can help to ensure that patient records are complete, accurate, and effective in supporting high-quality patient care.