charting by exception

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the keeping of a clinical record of the important facts about a patient and the progress of his or her illness. The patient's chart most often contains the history; laboratory reports; list of medications; results of physical examinations, consultations, and special diagnostic tests; treatments of the health care team; any problems; and the patient's response to interventions and treatment. See also problem-oriented record.
charting by exception a method of charting designed to minimize clerical activities; a notation is made only when there is a deviation from the baseline or expected outcome, or when a procedure or expected activity is to be omitted.

char·ting by ex·cep·tion

(chahrt'ing ek-sep'shŭn)
A method of documentation based on established standards of practice, for which reason only exceptions to these standards are documented.
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References in periodicals archive ?
Charting by exception is defined as "a shorthand method of documenting normal findings, based on clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions.
Whether you are documenting with a narrative style, using flow sheets or charting by exception, the purpose of documentation is to memorialize what occurred while you took care of your patient and to capture relevant information about the patient's condition and medical history.
Software modules include case scheduling, preference card management, inventory control, perioperative charting, charge capturing, charting by exception, instrument tracking and reporting.