charting by exception


Also found in: Financial.

charting

 [chahrt´ing]
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.
Mentioned in ?
References in periodicals archive ?
Charting by exception was the training standard when the EHR was instituted at the hospital (Kerr, 2013).
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.
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.
The system supports PeaceHealth's approach to charting by exception.
A charting by exception documentation system cannot be implemented without standards of care to support the documentation (Murphy & Burke, 1990).
Additionally, using past information, physicians can create a note, alter a few areas via charting by exception and insert any number of anatomical images for markup from the TouchWorks image library.
The purpose of this research was to explore the decision making of medical-surgical nurses who use charting by exception (CBE).