On the surface, this type of charting may seem like a practical solution. However, minimizing documentation can be risky and can be filled with potential liabilities if the charting definitions are unclear or if staff uses this as a lazy way to document. It is also extremely difficult to design the definitions so that exceptions will be well documented. They should be based on clearly defined standards of practice and pre-determined criteria for assessments and interventions. Facility definitions may be incomplete, vague, or poorly designed. Unfortunately, there is also a temptation to short cut charting such as just “cutting and pasting” findings in an electronic medical records.
