No exceptions: Staff need training for new forms
Explain why charting by exception is better
Despite the kudos many same-day surgery (SDS) managers give charting by exception, implementing that change can have obstacles. Generally, the forms are developed by a task force of nursing staff from all the affected areas (such as pre-op and PACU). Then, managers must train nurses in how to use the forms and explain why they are better than the more lengthy charts.
"It takes some staff education, reinforcing that this is all you need to document," says Cheryl A. Sangermano, RN, BSN, CNOR, service line manager for perioperative services and the laser center at Grant Medical Center Eye and Ear Hospital in Columbus, OH.
Charting by exception is a method of charting that requires nurses to make detailed notations only when the case doesn't follow the expected outcomes. (For more information, see Same-Day Surgery, November 1996, p. 128.)
Nurses looked at draft copy
When Grant Medical Center developed the perioperative flow sheet that uses charting by exception, task force representatives distributed a draft copy to nursing staff in the various departments, such as pre-op or PACU. (See Grant's perioperative flow sheet, pp. 143-146.) The task force made changes to the form based on the nurses' comments. The form also is reviewed every six months by Sangermano, the charting by exception task force, and staff nurses for possible revisions.
Sangermano created policies and procedures related to charting by exception, as well as implementation steps that nurses follow when using the form. The policies and procedures booklet became a reference for anyone with questions about how to document events using the form, she says.
Charting by exception also requires thorough inservice training, SDS managers say. At St. Joseph's in-house seminars, clinical nurse specialist Nancy Smith, MN, RNC, refers to articles on charting by exception, such as one that noted a 23% decrease in charting time at St. Luke's Medical Center in Milwaukee.1 (For information about a reference book on charting by exception, see source box, above.)
Smith also talks about omissions that nurses already make in traditional charting. For example, when they insert a Foley catheter, they don't necessarily mention that they used sterile technique. That is assumed. "When you do charting by exception, it's the same thing," Smith says.
Other training helps
In addition to seminars on how to chart with the new forms, Smith adds training on conducting a physical assessment, which helps nurses brush up on skills needed for good charting.
What do the physicians think about charting by exception? "They're supportive of nursing," says Smith. "If we can tell them it saves us time and it's better charting, they'll support it."
[Editor's note: Do you have a form you'd like to share with your peers? We're particularly interested in your same-day surgery critical pathways. For the forms you submit that we use, we'll send you a complimentary copy of 2000 and Beyond: Taking Your Same-Day Surgery Program Into the Next Century or another product of your choice. Please contact: Joy Daughtery, PO Box 740056, Atlanta, GA 30374. Telephone: (404) 262-5420. Fax: (404) 262-7837. E-mail: [email protected].]
Reference
1. Murphy J and Burke LJ. Charting by exception: A more efficient way to document. Nursing 90 1990; May:65-68. *
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