Are you charting by exception? Issue raises red flags for SDS programs

Some programs drop practice due to HCFA crackdown

A few years ago, charting by exception was praised as the greatest time saver for same-day surgery since electrocautery. Hospitals and surgery centers across the country jumped at the opportunity to use checkboxes that would document what was normal and to write out only the exceptions to normal patient conditions.

Then stories began to surface. A hospital in Puerto Rico was ordered to pay $600,000 to a patient who developed diskitis after he underwent surgery for a herniated disk.1 Besides accusing the doctor of negligence, the plaintiff claimed that due to charting by exception, the hospital failed to prepare, use, and monitor medical records properly.

Recently, word has circulated among same-day surgery administrators that some surveyors for the Health Care Financing Administration (HCFA) are getting stricter than drill sergeants when they encounter charting by exception. "Now some people are pulling back and saying, 'If the regulatory body, HCFA, which pays the bills, doesn't like it, we won't accept that,'" says Linda Groah, RN, MS, CNOR, service director for surgery at Kaiser Permanente in San Francisco.

So why is HCFA cracking down? Did same-day surgery programs go too far with charting by exception? Yes, some sources say. "A lot of people 'bastardized' charting by exception," Groah says. "There's not exactly a guideline for it."

In many cases, nurses were charting, but they weren't charting the specific care given to a specific patient, she maintains. "If there isn't a guidepost or a map for something, then all of sudden there are themes and variations," she says.

Nurses have gotten sloppy about documen t ing items such as weight, she says. Some patients develop problems with drug dosages, and pro viders aren't able to determine easily what's wrong because the patient's weight isn't on the chart, Groah says.

Critical pathways also figure in the improper use of charting by exception. "A lot of people thought, 'We have a critical path. Let's put it on path, then we don't have to chart what's happening to the patient.'"

The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, has six requirements for charting by exception. (See box at right.) It's fine to have information from the Joint Commission, say same-day surgery managers, but what about other organizations? "One of problems with all the different accrediting and regulatory bodies is that everyone has a different set of expectations," she says. "We get in a bind trying to meet everyone's expectations."

Just because one regulatory body accepts a practice, it's not carte blanche across the board, she warns. "They're not talking to each other," she explains. "We make a change, think it's A-OK, then another state body or another national body says, 'It's not meeting our needs.' The down and dirty of it is: Don't change it until you know it's accepted across the board."

Other sources agree that same-day surgery managers should do their homework before they implement charting by exception. When clients ask Melinda Whitney, RN, MS, CPHQ, CHE, coordinator of quality management services and senior consultant with The Quality Management Consulting Group in Columbus, OH, what to do, she wants to know how much research they've done on the practice and whether they've assessed their program's needs.

The next step is a trial implementation. Decide how large a trial to conduct, hold the trial, and assess the results, Whitney says. And start small, she advises. "You wouldn't flip over an entire system to charting by exception until one protocol was converted," she says.

Here are more tips from charting by exception experts:

· Expect to encounter staff resistance.

Nurses have been hearing this all of their careers: If they don't chart it, it didn't happen. "Nurses have a tendency to feel like they're not charting if they're not saying something all the time," says Penny Dykstra, RN, CNOR, director of emergency, observation, and outpatient surgical services at St. Joseph's Hospital of Atlanta. "Yet we're charting with charting by exception, but with symbols, not writing it out."

When nurses add unnecessary documentation to charting by exception and are asked about it, many say the next nurse will think they've done nothing, says Cheryl Bittel, MSN, CCRN, clinical nurse specialist at St. Joseph's. "They want to validate that they've done something, and they think charting validates what they do."

To avoid this mindset among your staff, give positive reinforcement to nurses who accurately chart by exception, Bittel suggests. "Keep praising them for saving time with their charting so they can spend more time with their patients."

· Spell out what is normal.

With charting by exception, you're following a policy, Dykstra points out. "Your policy has described everything that's normal, so when you put check marks there, it means everything is OK." (See chart, p. 76.)

The Joint Commission emphasizes having a standard of care to identify what you're charting against, says associate director Patricia Staten, MS, RN. "Someone can look at this patient chart and say, 'This is the exception, and this is the policy and procedure that guides the staff when documenting by exception,'" she says.

One issue left to resolve is who determines the standard of care or practice, and what references go into assuming that standard can hold up to litigation? "That's a biggie," Whitney says. Make sure nurses understand that if they fail to perform portions of a protocol, they're basically falling outside the standard, she advises. "So it's very important if you have A through Z set of steps, follow A through Z. If you fall out once, the protocol and standard haven't been met. If failure occurs, for example, you skip a couple of steps, and you check off the box that says you've done those steps, and you sign and date it, you've not only failed to complete the protocol, which is an ethical obligation to the patient, but you can be accused of falsifying a legal record. If they prove you didn't do it, it's not just your word that you did, but there's a document that said you did."

· List the timing of assessments.

St. Joseph's charts by exception to perform an assessment for outpatient surgery patients during preadmission testing, then again in outpatient holding if the surgical procedure is performed a few days after preadmit testing. If the patient will be admitted after surgery, an assessment is done on the floor after surgery. Instead of writing the entire assessments, nurses use a checkmark and a "C" for comprehensive assessments and a checkmark for abbreviated assessments.

· Educate staff about what to chart.

Differentiate between charting an assessment and charting items such as admissions and events, Bittel suggests. For example, nurses still need to chart that a patient was transferred from the OR to the bed or that a physician was notified about an abnormal lab. Confusion occurs because it's "normal" to notify a physician about such an event, but an abnormal lab is not normal for the patient. "Charting of events, procedures, and calling people for concerns or events still needs to take place."

· Re-educate.

St. Joseph's staff learned that re-education is critical to charting by exception. "It's about education, re-education, evaluation, and re-education again," Bittel says. "That's probably where we've failed: To look at this again every year and re- educate, and educate another way if we have to."

For staff buy-in, have risk managers speak. Nurses "are more apt to change behavior if they hear the legal standpoint - if they understand the charting and understand they're following policy."


1. Lama v. Borras. 16F.3d 473 PR (1st Cir. 1994).