Charting by exception on a clinical pathway

Area of Science:

• Nursing Informatics
• Healthcare Management

Background:

• Nurses dedicate significant time to patient care documentation.
• Inefficient documentation processes can impact workflow and patient care.

Purpose of the Study:

• To evaluate the impact of integrating charting by exception with clinical pathways on nursing documentation time.

Main Methods:

• A pilot project was conducted on an orthopedic/neurologic patient care unit.
• Chart-by-exception documentation was implemented alongside clinical pathways.

Main Results:

• Initial nursing documentation time averaged 2.5 hours per shift.
• Following the intervention, documentation time decreased to an average of 0.82 hours per shift.

Conclusions:

• Integrating charting by exception with clinical pathways significantly reduces nursing documentation time.
• This approach enhances nursing efficiency and workflow on patient care units.