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Children's Hospital Medical Center
Online Policies
IV-105 Documentation Guidelines for Charting By
Exception (CBE)
Original Date: 8/1/1983
Last Review Date: 8/26/2004
IV-105 Documentation Guidelines for Charting By Exception (CBE)
I.
General Guidelines for Charting
II.
Patient Care Assistant and Nursing Student Guidelines for Charting by Standards
III.
Guidelines for Admission Information
IV.
Guidelines for Interdisciplinary Plan of Care
V.
Guidelines for Assessments
VI.
Guidelines for Progress Notes
VII. Guidelines for Vital Signs, Height /Weight/Head Circumference
VIII. Guidelines for Intake and Output
IX.
Guidelines for Discharge Instructions Form
I. General Guidelines
A. Objective :
To document pertinent aspects of nursing care given to a patient. To assure
information is current, concise and pertinent. The charting should reflect the plan of
care and indicate the patient outcomes for all inpatients and short stay patients. When
possible, nursing care should also be documented as closely to the time as delivered.
B. Personnel :
RN
LPN
Non-licensed nursing caregivers
C. Implementation
1. Signature is indicated by user ID and password in the electronic medical record.
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2. Date and time defaults to system date and time unless otherwise indicated.
3. Abbreviations in charting must be from the approved CCHMC abbreviation list..
II. Patient Care Assistant and Nursing Student Guidelines for Charting by Standards
A. The initial assessment of patients and the initial plan of care upon admission or transfer
is the responsibility of the RN. Patient Care Assistants and Nursing Students may assist the
RN in the admission/transfer process and in the development of the care plan. Only Nursing
Students may do care plan revisions after consulting with the staff nurse assigned to the
patient and the RN must co-sign changes.
B. Patient Care Assistants and Nursing Students are to document daily care and
interventions in the electronic medical record.
1. Patient Care Assistants
a. Vital signs, height, weight, head circumference
b. I & O- oral intake and urine, stool and emesis.
2. Nursing Students
a. Vital signs, height, weight, head circumference
b. Q shift care
c. Admission Information
d. Interdisciplinary Plan of Care (IPOC)
e. I & O
f. Progress Notes
g. Assessments
C. The RN assigned to the patient is expected to do an assessment of all body systems
within two (2) hours of the start of the shift or prior to discharge (whichever comes first).
D. Abnormalities found in the systems assessment and summary statements of
interventions are to be charted by Nursing Students and viewed under Assessments.
Nursing Students may also chart in the progress notes. Students should make their notation
with their instructor's guidance. The RN, as soon as possible, reviews that he/she is in
agreement with the entry of the Nursing Student and documents this within the Assessment
Pathway.
III. Guidelines for Admission Information
This is the initial assessment of the patient/family upon admission which is completed in
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collaboration with the patient/family
A. Admission History
1. The Admission History is an assessment tool that the RN completes on every
patient in collaboration with the family.
2. Select age appropriate Admission History to be completed (Standard, Newborn, or
Adult based on admission type).
3. This tool is meant to be a screen of information so the RN can quickly assess a
large amount of data and focus his/her assessments where indicated.
4. The survey must be completed within 24 hours of admission. If the Admission
History is not able to be completed, then defer and document a reason. This should
happen only on rare occasions.
5. The Admission History may be utilized/reviewed by the unit if the patient returns
within six months of the original completion date. This information needs to be
reviewed by the parent/guardian with any changes indicated.
B. Allergies
1. Verify and list all allergies:
a. Medication/contrast
b. Foods
c. Products/latex
-or indicate no known allergies for each.
2. The care provider documents all allergies as perceived by the patient or family.
3. The allergies and the reactions are documented in the medical record.
C. Discharge Planning Admission Information
1. The discharge planning is information collected upon admission related to
anticipated needs of the patient/family.
2. Select age appropriate discharge planning to be completed.
D. Education Admission Information: This pathway is initiated by Nursing and completed
by all disciplines providing education.
1. Complete Education Admission Information by identifying the caretakers who
will be receiving education. This may also include the patient. Enter their name(s)
on the appropriate line and discuss the following with each of them:
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a. "Special Consideration" - those circumstances requiring special attention by
the educator. Used to format a teaching plan that fits the needs of the learner.
If a special consideration is identified, briefly explain in the space provided.
b. "Preferred Learning Style" - ask the learner how he/she learns information
best. There may be more than one area checked or none at all.
c. "Previous Knowledge Level" - discuss with the learner their understanding of
the admission diagnosis (topic). Obtain a baseline level of knowledge and
check the appropriate box.
2. Unit Education: Identify person being oriented by entering name in box (parent
and/or patient)
a. Unit education - as items are reviewed, check the box to the left of the item.
Some items include a space to the right for documenting more details about the
item.
b. Equipment - As items are reviewed check the box to the left of the item.
This should be done on admission, but should be updated throughout
hospitalization as equipment is added. There are blank spaces to write in any
additional equipment that may not be listed.
E. Admission Physical: This is the initial physical assessment of the patient done at the
time of admission. The initial assessment is to be documented in the Admission Physical
Pathway.
1. The general systems assessment standards are to be utilized when performing the
assessment. If an abnormality is found during the general assessment, an in-depth
assessment is to be done. For the presenting problem, the in-depth standards are to be
utilized.
2. Each system should be assessed with a general assessment or an in-depth
assessment.
a. If the assessment is normal, select body system(s) and document GA WNL.
b. If there is an abnormal finding, select body system(s) and document a
detailed assessment.
3. Pain Screening: A pain screen is required on admission for all inpatients. See
Clinical Practices Policy I-226 Pain Management.
4. Pain Assessment: If patient has pain then a pain assessment will follow the pain
screening.
a. Utilize the age appropriate (chronological) pain scale and document through
the Pain Pathway.
b. If the patient is developmentally, cognitively, or neurologically impaired,
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behavioral or physiological measures are used to assess pain. Indicate no pain
scale is appropriate and document a description of the patient's behavior.
Family member's accounts of the patient's past pain behaviors may be included
in the assessment.
5. Comfort Section:
a. On admission, document the patient/family have been educated on pain
management.
b. In conjunction with the patient/family, record the comfort goal in the words
used by the patient/family.
c. Also record the words the patient uses to describe pain.
d. Educate the patient/family about the potential limitations and side effects of
pain treatment.
6. At time of admission, document Vital Signs, Height (cm), Weight (kg), and Head
Circumference (cm) for less than 24 months in the Vital Sign Pathway.
F. IPOC: This is the patient specific plan of care to be developed in collaboration with
patient/family within the shift admitted. It will be used for the duration of the admission.
All sections of this pathway should be completed by the nurse. If there are circumstances
that arise preventing collaboration with the parent in person, contact the family by phone. If
the parent is still inaccessible, document that the parent was unavailable in the progress
notes. At the next available contact with the parent, the RN should review the focus of care
and make modifications, if necessary.
IV. Guidelines for IPOC
This section is the Interdisciplinary Plan of Care (IPOC) which is initiated on admission. It
incorporates the Focus of Care, Discharge Planning, Education Record and Home Health
Care Planning. Each part of the IPOC should be reviewed and/or documented against
within each shift.
A. Focus of Care: This can include a Standard of Care, medical diagnosis, symptoms and
patient/family needs.
1. Each focus contains goals and interventions. Goals are criteria that focus on a
measurable change in the status of the patient/family or focus on the end product of a
process. Interventions are criteria that focus on the major sequences of events and
activities in the delivery of patient care with a family focus that produces outcomes.
2. There can be multiple focuses of care which need to be individualized for each
patient/family. Under a Standard of Care goals and interventions can also be
modified. Additional focuses should be added as patient's status progresses or
changes.
3. Closure of focuses should occur when all goals and interventions have been
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completed. In this section comments can also be documented.
4. Upon transfer, all nursing focuses are evaluated. The transferring/sending RN
should review all focuses and close focuses that will no longer be pertinent.
5. Upon transfer, the RN receiving the patient must review goals and interventions
under open focus and discontinue/close all that are not applicable.
B. Discharge Planning: This section is intended for documentation of patient/family
progress toward meeting discharge criteria. This information in the discharge planning goal
is pulled from the IPOC.
C. Education Record: The Education Record is an interdisciplinary pathway documenting
patient/family education on every patient from admission through discharge. This part of
the Education Record is where the education content and evaluation are documented.
1. To document in the Education Record select appropriate education goal.
2. Choose from one of the following education content categories.
a. Health Topics
b. Freetext
c. Preprinted teaching plans
3. Select Learner- This corresponds to the information collected upon admission.
Select the learner to document against and note their readiness to learn with each
entry.
4. Expected Outcome/Goal- This indicates what will be required of the learner
(Verbalized Understanding, Demonstrates Independently, Information reviewed).
5. Evaluation- This section evaluates the learner's response to education. An
additional comment section is available for special circumstances that can not be
evaluated by information provided. If criteria are not met, continue with education.
The subsequent evaluations will be documented in the same manner
V. Assessments
Assessment of all body systems, pain, invasive lines, treatments, interventions, and Q shift
care is completed at least once a shift. Body systems requiring an in-depth assessment
should be done more frequently. The body systems and any invasive line assessments
should be completed within 2 hours of the start of the shift and prior to discharge.
A. Body Systems
1. An in-depth assessment is done if an abnormal finding is discovered during
general assessment. Additional comments may be documented under appropriate
body system.
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2. An in-depth assessment on a system should be done as it relates to reason for
admission.
3. See Standard of Care, Assessment Standards VI-101 for body system assessment
criteria.
4. It is possible to have an in-depth assessment if no abnormals were found.
5. HEENT and Gyn/Reproductive section are only completed if the patient condition
requires an in-depth assessment of those systems.
6. An appliance, permanent or semi permanent tube, or a functional (physical or
developmental) disability does not mean the assessment is abnormal and does not
warrant an in-depth assessment. At admission, any tube, appliance or functional
disability should be noted in the admission assessment.
7. Pain will continue to be assessed as part of the systems assessment..
B. Pain/Comfort Assessment
1. Pain Screening: Pain is routinely screened at least within each 8 hour shift and
PRN, unless contraindicated for psychiatric diagnosis. For patients with conversion
disorder or patients under the direct care of patients with conversion disorder or
patients under the direct care of psychiatry, see Clinical Practices Policy I-226 Pain
Management.
2. Pain Assessment: If patient is having pain, a pain assessment will follow a pain
screening.
a. Complete the date and time of the pain assessment.
b. Select age appropriate (chronological) pain scale and record the numeric
rating
c. Record the location, onset and description of pain.
d. Record an evaluation of present pain control.
i) If satisfactory, pain assessment is complete.
ii) If unsatisfactory, document interventions performed.
e. The time of reassessment should be within one hour of intervention.
f. For the information the nurse is unable to gather (i.e. Patient is asleep or non
verbal etc.) then use UTA and document.
3. The time of reassessment after an intervention is based on the nurses judgment and
type of intervention used.
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4. For patients on PCA's see Pharmacy and Therapeutics Policy II-115 Parent, Nurse
and Patient Controlled Analgesia.
5. For patients on continuous epidural analgesia see Pharmacy and Therapeutics
Policy II-114 Epidural Analgesia and Related Analgesia Techniques.
C. Invasive Lines: This pathway which includes CVC, EVD, PICC and new IV start
should be completed when appropriate.
1. CVC/PICC
a. Document or update the information related to the type of CVC/PICC
catheter.
b. Indicate the color/identifying descriptor of the lumen
c. Document the date of the dressing change, cap change, extension tubing
change, line change and med port access.
2. EVD-Document or update dressing or system changes.
3. New IV- Document in this pathway when an IV is started. Document the number
of IV attempts, site, personnel who attempted and type of catheter.
4. Document existing peripheral lines under New IV pathway for new admissions.
D. Treatment/Interventions and Q shift Care: Document or update the care delivered
throughout the shift when appropriate (i.e. tubes, dressings, drains, incisions)
1. When medical/surgical physical restraint is used, check the M/S Restraint
Assessment box each shift. Place a check in the M/S Restraint Assessment box to
indicate the RN is assessing on a regular basis (at least every 2 hours) the ongoing
need for medical/surgical physical restraint and the circulation check is complete 15
minutes after restraints are applied and every 2 hours. This check also indicates that
the patient's personal needs have been attended to (range of motion, nutrition and
elimination).
2. Place a check in the M/S Checkbox each shift. This check indicates that the
patient's safety is observed on a regular basis (not to exceed 2 hours as determined by
the patient's age or condition). Refer to Clinical Practices Policy I-214 Use of
Medical/Surgical and Behavioral Physical Restraints.
3. Developmental and safety approaches must be followed as outlined in the Aspects
of Care.
a. Indicate the location of the ID band.
b. Document each shift that the developmental standard is being followed.
4. Evaluation of all focuses should be done each shift. Documentation of the focuses
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should be done at least once a shift in a 24 hour period.
5. Guardrails/safety parameters are to be used on all infusion pumps for all TPN/IV
fluids and intermittent medications. If an override of the medication/fluid is required,
the RN should confirm the override on the first dose with the physician and document
the reason in the electronic medical record. The RN should document that
guardrails/safety parameters are maintained every shift.
E. Hourly Checks for Invasive Lines and EVD Sites: Invasive Lines and EVD Sites are to
be checked every hour. Document all pumps in use at 0600, 1400 and 2200.
VI. Guidelines for Progress Notes
A. Date and time all entries. Entries are to be labeled "Nursing".
B. Entries are made in the Progress Notes under the following circumstances:
1. At the time of a transfer, an in depth assessment of any abnormal findings is
written. The transferring/sending RN should review all focuses of care.
2. A progress note entry should be made at the time of unstable or significant events.
Always include specific time. If notification of physician occurred, include physician
name and time of notification.
3. Document procedures, tests or interventions done on patient. Note time, who
performed procedure, and patient response.
VII. Guidelines for Vital Signs, Height, Weight, Head Circumference
A. Vital signs
1. Place date and time when the vital signs were taken.
2. Indicate the route used for temperatures and document temperature in Celsius..
3. Document heart rate and respiratory rate. For blood pressure, fill in BP and
document position, site, and cuff size.
4. Record 02 sat range and indicate if on Room Air or Oxygen.
5. Record ICP reading when applicable.
B. Height, Weight and Head Circumference: Document admission height, weight and head
circumference (if applicable) within first 8 hours of admission..
1. Document Height/length (cm).
2. Document Weight (grams, kg).
3. Document Head Circumference (cm) for less than 24 months.
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4. Document Abdominal Girth (cm)
5. For Hematology/Oncology patients with Chemo HT/WT Event order then a co
signature is required by another RN.
.
VIII. Guidelines for Intake and Output
Date and time entry of Intake and Output. Intake and Output shifts are Days (0600-1359),
Evenings (1400-2159), Nights (2200-0559). "I and O" means only record PO Excluded
(nonspecific amounts of PO intake) and Output Excluded Sources (number of voids or
stools). "Strict I and O" measures specific amount of Intake and Output including diaper
weights.
A. Intake: Document source of Intake (oral, enteral, parenteral), amount absorbed and any
additional comments. Update sources of Intake as condition changes.
B. Output: Document source of output (urine, stool, emesis and drains/tubes), description
and any other comments.
IX. Guidelines for Discharge Instructions Form
This form is completed at time of discharge.
A. Page ___ of ___ should be completed upon discharge to indicate the number of forms
needed to complete Discharge Instructions.
B. Primary Care Physician: This section is completed upon discharge to ensure patient
follow-up and continuity of care.
C. Discharge Teaching: This section is completed upon discharge when teaching is
completed. List all education given during the hospital stay that is pertinent to home care,
including physician discharge instructions. The specific detailed education content is
documented on the Education Record. List all PEPs given.
D. Activity Restrictions: List any restrictions patient may have (e.g., no heavy lifting for 6
weeks or NA if no restrictions).
E. Return to School: If applicable, the school return date, as designated by the physician,
should be filled in here or place NA.
F. Discharge Diet: List type of diet plan patient should follow after discharge (e.g., regular
diet or special dietary needs).
G. Discharge Medications: Each medication is to be specifically listed with drug name,
dose/ concentration, frequency, time of last dose and time of next dose, duration and route
(do not use military time or medical abbreviations).
H. Drug/Food Interaction Discussed: Place a (√) checkmark in the yes box to indicate that
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drug/food interactions were reviewed for every medication prescribed. Place NA in this
section if there are no drug/food interactions.
I. Follow-Up Appointments or Tests: List any clinic, follow-up appointments, or tests
being arranged for discharge.
J. Equipment List: List any equipment patient is being discharged with. Leave blank if
patient is not being discharged with equipment.
K. Parent/Guardian Signature: Upon discharge, after Discharge Instructions have been
reviewed, the parent/guardian signs here.
L. Nurse Signature: The nurse that has completed and reviewed Discharge Instructions with
parent/guardian signs here.
M. Verified Identification of Parent/Guardian: In accordance with Nursing Policy II-103,
Identification of Patient and Parent, the nurse must verify the identity of parent/guardian at
the time of discharge. The discharge nurse checks this box once identification has been
verified.
N. Time of Discharge: The discharge nurse fills in the actual time of discharge here.
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Disclaimer: This policy is no longer valid after 9/27/2004 10:33:07 AM.
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