JCAHO Requirements

Here's what the Joint Commission on Accreditation of Healthcare Organizations says about charting by exception:1

" . . . the format is irrelevant as long as it documents the following six items:

    · initial assessments and reassessments;

    · nursing diagnoses and/or patient care needs;

    · interventions identified to meet the patient's nursing care needs;

    · nursing care provided;

    · patient's response to, and the outcomes of, the care provided;

    · abilities of the patient and/or, as appropriate, his/her significant other(s) to manage continuing care needs after discharge.

These items may be written word for word, or they may be written using references to a standard of care or protocol. And, in the case of the last item, discharge planning needs may be referred to another department or service of the hospital, such as social services."

Reference

1. Joint Commission on Accreditation of Health Care Organizations. Joint Commission Perspectives 1993; 13(2):9-10.