Question

A nursing assistant works in a health care unit that follows the charting by exception method to document patient records. The nursing assistant records both normal and abnormal findings. What does the nurse manager tell the nursing assistant in order to correct the records?

A) Continue charting by exception
B) Document only abnormal findings
C) Use narrative charting
D) Disregard charting altogether

Answer 1

The nurse manager should instruct the nursing assistant to document only abnormal findings when following the charting by exception method. This approach simplifies documentation and focuses on recording deviations from the norm or standard practices.

Step-by-step explanation:

When following the charting by exception method in a healthcare setting, the nursing assistant should be instructed to document only abnormal findings or significant observations that deviate from the norm. Since this method assumes that all standards of practice and normal findings are met unless otherwise noted, the record is mainly a tool for noting variations, issues or concerns. Therefore, the nurse manager should tell the nursing assistant to document only the abnormal findings (Option B) in order to correct the records. For example, if a patient's vital signs such as blood pressure, temperature, pulse, and respiration are within normal range, the nursing assistant would not document these details. However, if the patient has a spike in temperature or an irregular heartbeat, these abnormal findings must be recorded. In summary, charting by exception focuses on deviations from the established baseline or expected outcomes.