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Nursing Documentation: Writing What We Do

Charting by Exception in Aged Care

Type: eChapter
Book Title:	Nursing Documentation: Writing What We Do
Chapter:	4
This education is:	eligible for CPD

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Chapter 4: Charting by Exception in Aged Care

Overview:

Includes step by step guidelines for documenting care at the completion of a shift
Addresses issues to introduce when charting by exception
Evaluates the advantages of exception writing
Points towards supplementary reading

Description:

Charting by exception (CBE) is an exciting development in nursing documentation. This chapter focuses on charting by exception and includes guidelines, support processes as well as issues to consider when implementing this new practice.

Topics:

Guidelines For Charting By Exception
- Support Processes For Charting By Exception
Some Issues To Consider When Introducing Charting By Exception
Benefits Of Exception Writing
In Summary
References
Suggested Reading

Speakers / Authors:

Gaye Witney RN (Div 1), B Ed, ADT & D, Grad Cert Ger, ACMS, Grad Cert IE & T, MRCNA, AIMM
Gaye is currently co-ordinator of a program in aged care at Kangan Institute of TAFE, Broadmeadows, Victoria, Australia, which offers the Certificate IV in Health (Nursing), Personal Care Worker Course, HACC Course and Patient Services Attendant Course. Her past positions have included Outcome Standards monitor and RCI review officer with the Commonwealth Department of Health and Family Services, and director and deputy director of nursing in various nursing homes.

Gaye says she first became interested in documentation systems while working in aged care facilities and more so when she was a standards monitor. Being a firm believer of ‘smarter not harder’, she feels a system of exception writing addresses this philosophy while utilising the basic principles of the nursing process.

Christine Crofton RN (Div 1), RM, Grad Cert Ger, Dip E & T, ADT & D, MRCNA
Christine is currently director of nursing of a 45-bed nursing home in Melbourne. Her past positions have included executive officer of a division of Family Medicine, director of nursing of a 60-bed nursing home and Victorian state co-ordinator of TARCRAC. Chris says that she has become passionate about efficient methods of documentation for aged care nurses as the current, commonly used system is time-consuming and repetitive. Nurses generally wish to devote more time to interaction with residents, whilst having access to a crisp and concise picture of the resident’s care needs, enabling contemporary, professional nursing care.

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