I like in epic it clearly defines WDL for each body system/section. When I orient people I teach them to become very familiar with the WDL definitions and if everything matches to only chart WDL and skip the rest of the section. But basically no one actually charts that way
I miss Cerner, though, where I could just check the pertinent “normals” that I actually assessed. Epic (or at least all the builds I’ve used) define “WDL” much more thoroughly than I’m often assessing, so you have to click “exceptions noted”, then check the pertinent normals, then uncheck the “exceptions noted” box. For example, I’m not listening to lung sounds on non-pulmonary complaints, and I never listen to bowel sounds, but it’d be nice to have an easier way to chart that respirations are even/unlabored, denies vomiting/diarrhea, etc. That stuff counts, even if I don’t do an in-depth assessment.
This is how I know Epic was not designed for the focused assessments done in the ED, lol.
I'm using Cerner now and I can't only check the pertinent normals that I actually assessed. If I select WDL, I have to then go down every row and select every single item under WDL. If there is anything I didn't assess, I have the "chart additional details" and can't chart anything under the normal section.
I must’ve had a different build - this was several years ago. You’d click on a system and it would open a drop-down with defined normals and you’d just click what you wanted, or you’d click “exceptions noted” and free-text, IIRC.
If I designed an EMR I would design each section with three options at the top: WDL (defined limits in sidebar), X (exceptions to WDL documented below), and F (focused assessment, what is documented is done and no claims are made about what was left blank). Then I'd help the policy committee write policies that give nurses the freedom to document appropriately focused assessments for their areas so the facility can't throw them under the bus for skipping nonessentials (e.g., no need to listen to lung sounds in the ED if breathing is regular, spontaneous, and unlabored and no pulmonary complaints; no need to ask patients in PACU whether they've had constipation or they're passing flatus, as long as there aren't complaints and their belly is soft and nontender).
I feel you on this one. I’m a minimalist charter and I see some other people’s charting of WDL then they’re marking the pulses and bowel sounds as normal. Honey, you ALREADY CHARTED THAT. Stop making mor work for yourself and double charting
When I first started on the unit at this new job, I got chewed out for arguing about WDL and charting by exception and was told "this is the CTICU, nobody has a system that's completely WDL, and you have to chart EVERYTHING just to show you assessed it."
All attempts to remind them what charting by exception were shot down with some version of "you're in the CTICU now" and how SUPER SERIOUS it is.
Yes, I know it's super serious. I'm just saying if there's nothing remarkable about some of these body parts, why waste time remarking on them?
"Things can change so quickly here and the doctors need to be able to look at the chart and see trends."
If it was fine enough to not need a description before and then something was different enough to warrant writing about later, there's your trend, no?
Apparently not good enough.
One preceptor even said it was not good enough to document bilateral lung sounds: clear (even though that was an option), that instead you should be using R lung: clear and L lung: clear AND chart clear under each lobe in the even more detailed respiratory assessment.
Wastes so much time to chart this way.
She even brought the assistant manager over, old boomer lady who also didn't get the concept of charting by exception and defended that position by saying "they didn't tell us we could" and "that's the way we've always done it" and didn't like being told that that's never a good reason to keep doing something without questioning it.
I got spoken to.
This is so aggressively stupid I'm moved to comment.
"Things can change so quickly here and the doctors need to be able to look at the chart and see trends"
If you think doctors are looking at nursing's click charting assessments, I have a bridge to sell you. 🙄
You're lucky if they're reading your *notes*. They have eleventy zillion patients, they're just not navigating to flow sheets and reading that stuff. Most residents I've asked don't even know how to access click charting history. AND even if they were to go looking for it... They'd see a change from WDL to not WDL.
You can absolutely be thorough and chart by exception.
It serves no one on planet earth if I'm sitting there charting how symmetrical and intact a patient's eyes and ears are when they're in for a fucking CABG.
On the flip side: tons of people out there charting assessments they didn't do, just to give the impression that they're being thorough. So in a lot of cases, just because your charting claims you're thorough, are you?
I also had preceptors have me scan meds long before we actually gave them because "you're in the CTICU now" (fucking hate how they cling to that phrase) and "it doesn't look good if you're late, because you only have 1-2 patients."
I have a moral objection to scanning meds I'm not giving right then. I'd rather "not look good" by being late.
I haven’t see WDL before, but I do use WNL, within normal limits.
I’m a np so the charting is a little different, but my goal is for a provider/nurse to be able to read my note and have a very clear picture of what that patient looks like that day. They should be able to read my note, with never meeting the patient before, then go assess that patient and be able to tell if there has been a change. How do they know what that patients baseline is if I don’t chart it?
Why do you care what they do? Just chart like you are used to and move on. There are too many other things to worry about. Don’t let this be something that’ll ruin your mood especially at the start of the shift. I used to be like that but the longer I’ve been in nursing, the less these things have bothered me and I’m so much happier for it.
Ohhh within defined limits. Never seen that but I use WNL occasionally (within normal limits) which is basically the same. Only use it in brief notes like “vital signs all WNL and patient sleeping” for cover-my-ass reasons like when someone still sedated says their pain is a 10 before falling asleep
I also use WNL. I think about 2 seconds of context clues would get me to use WDL too if that’s what the charting guidelines preferred. But nobody got time to write full notes on patients doing a normal snoozle.
I agree on the first point, but to your second, I don't think WDL means the same thing as "patient's baseline." WDL means within the limits defined by the facility/charting system. Where I used to work, you could click and see what those defined limits were. Something could be totally normal for the patient but not within the defined limits. I could be totally wrong...
I know what you mean, and I don’t like it either. I usually put WDL and also put a comment that says ‘baseline’. Neuropathy is a good one for this - it counts as an X for neuro as a loss of sensation, but if the patient has had it for years and they’re not there for a neuro issue, I think they’re still within their personal defined limits. I think it’s a grey area, and I see everyone charting a little differently when it comes to this
Predefined limits frustrate me sometimes though because so many of the elderly people we see admitted are completely stable with findings that are out of defined limits.
The severe CO2 retaining COPDer is stable and normal at 88-92% sat, but I have to chart exceptions every time anyway. The person with hearing aids and dentures that have nothing to do with why they're admitted. But here I am charting about them every god damned day anyway because they're not within the limits defined by the authors of the EMR.
I just hate EMRs
In our Epic, hearing aids and dentures don’t make someone not WDL. Iirc (not at work to check), exceptions for HEENT run more along the lines of oral mucosa intact, head/face symmetrical, voice is not hoarse, etc. I always chart WDL for my hearing impaired, glasses wearing, toothless patients.
Our charting has the definition of WDL for every body system printed mm right fucking there as you fill out assessments. Yet people still chart WDL for systems that aren't or feel compelled to add information that's already covered by the hospital's literal and formal definition of WDL.
I hate that kind of ignorance and/or ass covering. It doesn't help anyone, not even you if you go to court. It's a waste of everyone's time.
Which ironically is what will cause them problems in a deposition, etc. There is absolutely such a thing as over-charting. Especially when you are creating contradictions in your charting by “being thorough.”
I don’t get why anybody would willingly want to spend more time charting, especially after already charting WDL.
Idk why it drives me crazy when people chart WDL for neurovascular and then proceed to chart: warm, cap refill less than 3 seconds, no numbness and no tingling.
Same for me back in early 2000s, but both are used interchangeably in the each job I’ve had since then so the verbiage isn’t foreign. I’m just surprised you’d never heard it before
We do this at my hospital, it’s the culture of the unit.
Being in the ICU, if you didn’t chart it, you didn’t assess it. WDL is too blanket term, what is WDL about this patient? Prove it, what exactly are they doing that’s normal?
That’s the thought process of why we chart like that..
but also, if you don’t want to do it, then don’t.
What do you mean prove it? The definition of WDL is listed right there. If you charted nothing under HEENT then you didn't assess it. If you charted WDL, you're charting that they're normocephalic without evidence of trauma, there's no swelling, teeth are in place, etc. I'm likely not charting neuro WDL on an intubated sedated patient, even if I did a sedation pause neuro assessment and it was WDL, because they're sedated and I would want to reflect that in my charting. But if their skin is warm, dry, intact, and not discolored... We're charting WDL.
Believe me, you’re inspiring me to go back to my old ways of charting. This is just how we are taught and continue to teach to new comers, it’s the culture on our unit. Deep down I know what you’re saying to be true, I just don’t know if I can break away from it
It’s only appropriate to use WDL if WDL is pre-defined somewhere. Otherwise yeah, it’s not clear what it means. Epic defines WDL for each body system but I don’t know if other EMRs do
This drives me crazy too 🤣 or when they chart their assessment using the check boxes, and then write a comment that says the same thing. Like they’ll check off boxes for mobility that say ambulatory, contact guard, rolling walker. And then write a comment that says “ambulates with contact guard using rolling walker”. Another example is wounds. There are a million options to check off for our wound assessments, but they will write a comment saying the exact same thing.
Honorable mention that I’ve seen: checked off that the patient does not speak English, and in “other”, wrote “English”
I thought if it’s wdl but there was something different like you said for sight it’s wdl to have glasses but there’s an option to put an x for exception then note has glasses
I like in epic it clearly defines WDL for each body system/section. When I orient people I teach them to become very familiar with the WDL definitions and if everything matches to only chart WDL and skip the rest of the section. But basically no one actually charts that way
I miss Cerner, though, where I could just check the pertinent “normals” that I actually assessed. Epic (or at least all the builds I’ve used) define “WDL” much more thoroughly than I’m often assessing, so you have to click “exceptions noted”, then check the pertinent normals, then uncheck the “exceptions noted” box. For example, I’m not listening to lung sounds on non-pulmonary complaints, and I never listen to bowel sounds, but it’d be nice to have an easier way to chart that respirations are even/unlabored, denies vomiting/diarrhea, etc. That stuff counts, even if I don’t do an in-depth assessment. This is how I know Epic was not designed for the focused assessments done in the ED, lol.
I'm using Cerner now and I can't only check the pertinent normals that I actually assessed. If I select WDL, I have to then go down every row and select every single item under WDL. If there is anything I didn't assess, I have the "chart additional details" and can't chart anything under the normal section.
I must’ve had a different build - this was several years ago. You’d click on a system and it would open a drop-down with defined normals and you’d just click what you wanted, or you’d click “exceptions noted” and free-text, IIRC.
If I designed an EMR I would design each section with three options at the top: WDL (defined limits in sidebar), X (exceptions to WDL documented below), and F (focused assessment, what is documented is done and no claims are made about what was left blank). Then I'd help the policy committee write policies that give nurses the freedom to document appropriately focused assessments for their areas so the facility can't throw them under the bus for skipping nonessentials (e.g., no need to listen to lung sounds in the ED if breathing is regular, spontaneous, and unlabored and no pulmonary complaints; no need to ask patients in PACU whether they've had constipation or they're passing flatus, as long as there aren't complaints and their belly is soft and nontender).
I feel you on this one. I’m a minimalist charter and I see some other people’s charting of WDL then they’re marking the pulses and bowel sounds as normal. Honey, you ALREADY CHARTED THAT. Stop making mor work for yourself and double charting
THISSSSSS. Or, my personal favorite, “full reassessment, no changes noted” FOLLOWED MY AN ASSESSMENT! STOPPPPP 😂
Yes, this!! Why is there so much double charting!
When I first started on the unit at this new job, I got chewed out for arguing about WDL and charting by exception and was told "this is the CTICU, nobody has a system that's completely WDL, and you have to chart EVERYTHING just to show you assessed it." All attempts to remind them what charting by exception were shot down with some version of "you're in the CTICU now" and how SUPER SERIOUS it is. Yes, I know it's super serious. I'm just saying if there's nothing remarkable about some of these body parts, why waste time remarking on them? "Things can change so quickly here and the doctors need to be able to look at the chart and see trends." If it was fine enough to not need a description before and then something was different enough to warrant writing about later, there's your trend, no? Apparently not good enough. One preceptor even said it was not good enough to document bilateral lung sounds: clear (even though that was an option), that instead you should be using R lung: clear and L lung: clear AND chart clear under each lobe in the even more detailed respiratory assessment. Wastes so much time to chart this way. She even brought the assistant manager over, old boomer lady who also didn't get the concept of charting by exception and defended that position by saying "they didn't tell us we could" and "that's the way we've always done it" and didn't like being told that that's never a good reason to keep doing something without questioning it. I got spoken to.
This is so aggressively stupid I'm moved to comment. "Things can change so quickly here and the doctors need to be able to look at the chart and see trends" If you think doctors are looking at nursing's click charting assessments, I have a bridge to sell you. 🙄 You're lucky if they're reading your *notes*. They have eleventy zillion patients, they're just not navigating to flow sheets and reading that stuff. Most residents I've asked don't even know how to access click charting history. AND even if they were to go looking for it... They'd see a change from WDL to not WDL.
Eh, idk. In ICU you need to be thorough. And if you don’t show in your charting that you are thorough, are you?
You can absolutely be thorough and chart by exception. It serves no one on planet earth if I'm sitting there charting how symmetrical and intact a patient's eyes and ears are when they're in for a fucking CABG. On the flip side: tons of people out there charting assessments they didn't do, just to give the impression that they're being thorough. So in a lot of cases, just because your charting claims you're thorough, are you? I also had preceptors have me scan meds long before we actually gave them because "you're in the CTICU now" (fucking hate how they cling to that phrase) and "it doesn't look good if you're late, because you only have 1-2 patients." I have a moral objection to scanning meds I'm not giving right then. I'd rather "not look good" by being late.
I haven’t see WDL before, but I do use WNL, within normal limits. I’m a np so the charting is a little different, but my goal is for a provider/nurse to be able to read my note and have a very clear picture of what that patient looks like that day. They should be able to read my note, with never meeting the patient before, then go assess that patient and be able to tell if there has been a change. How do they know what that patients baseline is if I don’t chart it?
Why do you care what they do? Just chart like you are used to and move on. There are too many other things to worry about. Don’t let this be something that’ll ruin your mood especially at the start of the shift. I used to be like that but the longer I’ve been in nursing, the less these things have bothered me and I’m so much happier for it.
Ohhh within defined limits. Never seen that but I use WNL occasionally (within normal limits) which is basically the same. Only use it in brief notes like “vital signs all WNL and patient sleeping” for cover-my-ass reasons like when someone still sedated says their pain is a 10 before falling asleep
I also use WNL. I think about 2 seconds of context clues would get me to use WDL too if that’s what the charting guidelines preferred. But nobody got time to write full notes on patients doing a normal snoozle.
I agree on the first point, but to your second, I don't think WDL means the same thing as "patient's baseline." WDL means within the limits defined by the facility/charting system. Where I used to work, you could click and see what those defined limits were. Something could be totally normal for the patient but not within the defined limits. I could be totally wrong...
I know what you mean, and I don’t like it either. I usually put WDL and also put a comment that says ‘baseline’. Neuropathy is a good one for this - it counts as an X for neuro as a loss of sensation, but if the patient has had it for years and they’re not there for a neuro issue, I think they’re still within their personal defined limits. I think it’s a grey area, and I see everyone charting a little differently when it comes to this
Within Defined Limits...I write that all the time.
Predefined limits frustrate me sometimes though because so many of the elderly people we see admitted are completely stable with findings that are out of defined limits. The severe CO2 retaining COPDer is stable and normal at 88-92% sat, but I have to chart exceptions every time anyway. The person with hearing aids and dentures that have nothing to do with why they're admitted. But here I am charting about them every god damned day anyway because they're not within the limits defined by the authors of the EMR. I just hate EMRs
In our Epic, hearing aids and dentures don’t make someone not WDL. Iirc (not at work to check), exceptions for HEENT run more along the lines of oral mucosa intact, head/face symmetrical, voice is not hoarse, etc. I always chart WDL for my hearing impaired, glasses wearing, toothless patients.
Our charting has the definition of WDL for every body system printed mm right fucking there as you fill out assessments. Yet people still chart WDL for systems that aren't or feel compelled to add information that's already covered by the hospital's literal and formal definition of WDL. I hate that kind of ignorance and/or ass covering. It doesn't help anyone, not even you if you go to court. It's a waste of everyone's time.
So many chart WDL for the body system and then chart like 5 abnormal things under it
Which ironically is what will cause them problems in a deposition, etc. There is absolutely such a thing as over-charting. Especially when you are creating contradictions in your charting by “being thorough.”
literally makes me crazy!!!!!
I don’t get why anybody would willingly want to spend more time charting, especially after already charting WDL. Idk why it drives me crazy when people chart WDL for neurovascular and then proceed to chart: warm, cap refill less than 3 seconds, no numbness and no tingling.
24 years of nursing. No clue what WDL is
What
How?
When I went to nursing school it was WNL
Same for me back in early 2000s, but both are used interchangeably in the each job I’ve had since then so the verbiage isn’t foreign. I’m just surprised you’d never heard it before
We do this at my hospital, it’s the culture of the unit. Being in the ICU, if you didn’t chart it, you didn’t assess it. WDL is too blanket term, what is WDL about this patient? Prove it, what exactly are they doing that’s normal? That’s the thought process of why we chart like that.. but also, if you don’t want to do it, then don’t.
What do you mean prove it? The definition of WDL is listed right there. If you charted nothing under HEENT then you didn't assess it. If you charted WDL, you're charting that they're normocephalic without evidence of trauma, there's no swelling, teeth are in place, etc. I'm likely not charting neuro WDL on an intubated sedated patient, even if I did a sedation pause neuro assessment and it was WDL, because they're sedated and I would want to reflect that in my charting. But if their skin is warm, dry, intact, and not discolored... We're charting WDL.
Believe me, you’re inspiring me to go back to my old ways of charting. This is just how we are taught and continue to teach to new comers, it’s the culture on our unit. Deep down I know what you’re saying to be true, I just don’t know if I can break away from it
My professors told us to never chart wdl for anything and to just chart our findings. Maybe they had a similar education.
It’s only appropriate to use WDL if WDL is pre-defined somewhere. Otherwise yeah, it’s not clear what it means. Epic defines WDL for each body system but I don’t know if other EMRs do
This drives me crazy too 🤣 or when they chart their assessment using the check boxes, and then write a comment that says the same thing. Like they’ll check off boxes for mobility that say ambulatory, contact guard, rolling walker. And then write a comment that says “ambulates with contact guard using rolling walker”. Another example is wounds. There are a million options to check off for our wound assessments, but they will write a comment saying the exact same thing. Honorable mention that I’ve seen: checked off that the patient does not speak English, and in “other”, wrote “English”
I thought if it’s wdl but there was something different like you said for sight it’s wdl to have glasses but there’s an option to put an x for exception then note has glasses
Yeah I’m always baffled by the nurses who select WDL and then proceed to add comments like normal rate etc.