Nursing Charting By Exception

Congresswoman Shelley Berkley cares about veterans

I know Congresswoman Berkley cares about veterans. This is what I was trying to get across last election, but couldn't due to a real physical health problem that went deliberately untreated: http://www.webcommentary.com/php/ShowArticle.php?id=andersonm&date=110520 And I would cut off my arms for Sue Lowden!

As I continue to recover and can write with greater clarity, I will do so. And I'll stick to one thing at a time (e.g. how I became depressed/SI over the thought of getting anything from the taxpayer to go to school). Here's what I ask. When I ask people to find people to talk to them, please do it, because they are credible people who can vouch for me. Find a lady named Robin Generaux. She will corroborate what I say about how I got myself dropped from the VA Voc Rehab program, where I was literally getting paid to go to school. Also, the timing of certain things in terms of when I became depressed/SI (i.e. untreated hypothyroidism that the VA mismanaged) will corroborate what I say. I crashed so bad (when I look at the symptoms of delirium, that's what I had), I literally forgot who I am as a person by the end of the general election. I made myself sound like a worse human being. I never sparred with the VA over education benefits! I've never been able to follow through on going to school with taxpayer money. Of course, the VA was more than willing to accomodate me because they didn't know I had no access to healthcare at the VA nor that the VA was calling my thyroid disorder a delusion and belief that it needed to be treated "threatening" and "delusional." So they just looked at me as a poor investment when I got myself dropped from the VA Voc Rehab program. Yet, it was precisely because I got myself dropped from the program that enabled me to keep attending school depression free.

See: http://www.noanthraxvaccine.net/images/collegetranscripts.jpg My psych professor was Rich Lowe. He would remember me, I'm sure. I practically helped lead the class. I made sure to keep that class, even as I wasn't getting healthcare through the VA nor on thyroid medication, because he motivated the hell out of me. I think he would vouch for me, too. On paper, I was in another state according to the VA Voc Rehab program. In reality, I was finishing the semester. I will write more about this in the future.

Charting by exception - Multiply

CBE system is a complete, clear, logical, accurate, and cost-effective system that streamlines nursing documentation. In reporting by exception, only significant events are described; abnormal assessment findings; IV solutions that need to be changed within the next two hours; unusual treatments, interventions, or pertinent incidents from the current and/or previous shift; special one-time orders needing completion by the next shift; and physicians’ orders needing to be clarified or obtained.

Decreasing the amount of time spent on documentation can have a positive effect on productivity and staffing. More time for direct patient care allows a nurse to care for more patients or to increase the depth of care provided to the same number of patients. This is important, as the acuity of patient care in acute, long-term, and home health agencies continues to rise.

CBE Symbols :

When a patient is admitted, the information about the patient is recorded in a database. The database becomes a permanent part of the patient record and is available to all members of the health care team. Databases incorporate CBE to varying degrees. Most nursing documentation systems use CBE symbols to document baseline physical and in some cases, psychosocial assessment findings.

A patient care protocol is a list of standardized nursing interventions dealing with the expected clinical course of a specific patient population. The interventions guide the nurse to monitor for and prevent potential health problems. In many instances, protocols are related to a medical diagnosis, procedure, or therapy. Example would be a nurse following a patient care protocol for postoperative care. The nurse compares the patient’s findings to the negative, or normal, criteria given in the "Guidelines for Use" usually printed on the base or back of the flow sheet. If the assessment is the same as described on the form (i.e., if findings are normal, or negative), a check mark ( ) is placed in the category box. If the assessment differs from the findings described on the form, then an *  (asterisk) is placed in the category box. This indicates abnormal, or positive,
 findings. If the patient’s status remains unchanged from a previous significant entry, then an arrow is drawn from the previous category box to the box indicating the time of the new assessment. The arrow eliminates the need to rewrite the same abnormal findings, and gives a dynamic overview of the patient’s status at a glance. Any differences or variations noted should be described in the "Significant Finding" section in detail. It is imperative that all assessment orders that are documented with CBE symbols have predefined norms clarified either in the "Guidelines for Use" or documented in some manner within the patient’s chart. Many health care agencies document norms for assessments on the patient’s plan of care.  See CBE example and documentation of abnormal or positive findings.

Fundamental Nursing Skills and Concepts

Legal aspects of health care administration

Nursing malpractice

Textbook of basic nursing

Nursing documentation, a nursing process approach