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.
Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health, Seventh Edition. © 2003 by Saunders, an imprint of Elsevier, Inc. All rights reserved.

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.
Medical Dictionary for the Health Professions and Nursing © Farlex 2012
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Charting by exception was the training standard when the EHR was instituted at the hospital (Kerr, 2013).
Facilities tend to defend this kind of charting irregularity on the basis of "charting by exception," where a note is made only when a routine action does not take place.
One workgroup was assigned the task of determining when "charting by exception" would be allowable and when it would not be permissible or indicated.
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.
Charting by exception creates a particular dilemma for lawyers, because it allows nurses to testify that "if no abnormality is charted, then everything must have been normal." To counter this claim, it is important to correlate the nurse's notes with any other graphical notes, such as vital-sign sheets, that may be in the chart.
A charting by exception documentation system cannot be implemented without standards of care to support the documentation (Murphy & Burke, 1990).
The purpose of this research was to explore the decision making of medical-surgical nurses who use charting by exception (CBE).
The system supports PeaceHealth's approach to charting by exception. Because "normal" definitions are available via online help, expert users can work efficiently while novices can easily get the guidance they need.