A nurse works in a hospital that utilizes a charting by exception documentation system

Question

When documenting care and assessments using the charting by exception system, the nurse may not address all of the sections on a client's flow sheet, especially if the client did not require this particular care. In order for the nurse to identify that these areas were addressed, but no care was needed, the best action is to:
1. Leave them blank.
2. Leave them blank, but then add an extensive explanation in the progress notes section of the chart.
3. Write N/A on the flow sheet in the areas that are not applicable to that client.
4. Make sure this information gets passed along in the shift report.

Answer 1

Correct Answer: 3
Rationale 1: It is never a good idea to leave blanks in any charting area since it implies that the area was ignored.
Rationale 2: It is never a good idea to leave blanks in any charting area. Adding the information in the progress notes is not an appropriate use of that section.
Rationale 3: Many nurses are uncomfortable with the CBE system and believe that if something was not charted, it was not done. A suggestion to address this would be to write N/A on the flow sheets where the items are not applicable to the client, and not leave the spaces blank. This would avoid the possible assumption that the assessment or intervention was not done by the nurse.
Rationale 4: Passing information along in the report is a good way to ensure continuity of care for clients, but this would only be an oral report, not written documentation.