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How to chart by exception

Smith, Linda S. RN, MS, DSN

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Charting by exception

Linda S. Smith is an assistant professor in the school of nursing at Oregon Health & Science University in Klamath Falls, Ore.

CHARTING BY EXCEPTION (CBE) or variance charting is a system for documenting exceptions to normal illness or disease progression, using a shorthand method of charting what's usual and normal. You make check marks or write your initials in certain places on the CBE flow sheets.

This type of charting is often done on flow sheets that are based on preestablished guidelines, protocols, and procedures that identify and document the standard patient management and care delivery. You need to make additional documentation when the patient's condition deviates from the standard or what's expected.

Some advantages of CBE:

  • You spend less time on paperwork and charting because the documentation system is streamlined.
  • Documentation consistency is enhanced because the system reduces individual variations in documentation quality and quantity.
  • Confusing, redundant charting is reduced or eliminated.
  • Variances stand out clearly as needing intervention.
  • You can spend more time with patients.
  • Protocols reduce the time you spend asking primary care providers for routine orders.
  • Patient outcomes are clearly identified and measured, so you can easily validate your role and workload.
  • Physicians and other health care providers can more easily read and understand the health care record, enhancing continuity of care.
  • Preestablished care guides and clinical pathways become easy references and reminders, reducing the risk of inadvertent deviation from the standard of care.
  • If your record is called into court, you have timely documentation that identifies reasons for any clinical pathway deviation and the subsequent decisions and interventions.
  • Because the charting system is based on specific clinical pathways, opposing lawyers in a court case can't choose the one that best reinforces their case from hundreds of pathways. Clearly documented variances can help you avoid charges of malpractice.

Because minimizing documentation is risky, well-designed flow sheets are crucial in a CBE system. If the CBE documentation doesn't give a clear, accurate description of the patient's condition, write it out in a narrative note. If you're called into court several years later, you'll be able to reconstruct an accurate picture of your patient's condition.

Before implementing a CBE system, employers need to make sure that their charting policies don't conflict with state and federal regulations or those of accreditation agencies such as the Joint Commission on Accreditation of Healthcare Organizations. Risk managers, facility attorneys, interdisciplinary committees, and regulatory spokespersons such as state human services representatives should review and approve any CBE plans. These reviews and decisions need to be well documented.

All CBE policies, protocols, standards, procedures, clinical pathways, and staff training need to be in place before CBE implementation.

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