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Charting By Exception: What To Be Aware Of When Taking Shortcuts

We'll walk through some of the major considerations nurses should be aware of when using a charting technique like CBE.

March 13, 2019

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Paperwork and charting might be necessary, but any nurse will tell you she’d rather be spending that time with her patients. That’s where charting by exception comes in. This method of charting — unlike the more expanded, more detailed narrative charting — allows any member of a patient’s care team to report only the things that are out of the norm for that patient.

It’s the solution many busy healthcare professionals depend on, most notably nurses. That said, charting by exception can create risks if not done properly.


What Is Charting By Exception?

Charting by exception (CBE) is a method of medical notation in which nurses only provide notes if there are deviations from a patient’s norm or baseline. It was designed to reduce the amount of documentation needed on a patient, freeing up nurses to either tend to more pressing tasks or spend more time engaging with the patient.

Every facility has its own standards for defining what’s “normal” for a patient in its care. For example, a women’s care team would specify what a normal well-woman exam entails. CBE in this case would only list occurrences outside of the well-woman norms, such as abnormal pap smears or irregular periods. In any given facility, if these norms are clearly laid out for staff to follow, it can help care teams identify any unexpected outcomes to be noted on the patient’s chart.


What Are the Main Elements of Charting By Exception?

To work properly, the CBE technique needs to have well-defined guidelines and standards of care in place. There are three major elements or components that characterize the technique.

1) Flow Sheets

These sheets list what constitutes as “normal findings” for your particular facility. As a nurse, you’d be expected to provide notes only when there are variations from those expected results.

2) References to Other Standard Practices & Documents

This may include documents like lab results, as well as any guidance on how to evaluate them. Or, it could include meal charts and information on what falls out of the norm for a patient’s eating (i.e., too much or not enough).

3) Bedside Charting

In essence, this is the expectation that all flow sheets and additional documents are to be left at patients’ bedside so that any healthcare practitioner can access the information at any given time.

CBE loses its efficacy and can become problematic if any one of these elements is neglected.


What Are the Risks of Charting By Exception?

While nurses may enjoy some extra time on their hands for other things, CBE can also present some unintended consequences if the practitioner isn’t diligent. Here are some of the most common risks associated with techniques like CBE that you should look out for.

Risk #1: Important details could be left out.

Everyone makes mistakes, and a nurse in a rush who doesn’t double- and triple-check her work can miss vital details. For example, if a patient skips a meal, this could be noted as abnormal under CBE. But if the nurse doesn’t take the time to review the medications that a patient might be taking, she could be misidentifying side effects like nausea or loss of appetite as irregular when, in fact, they’re normal outcomes for that specific patient.

Risk #2: Charting at irregular times might prevent you from catching subtle changes.

If hours go by between assessments, a patient could experience myriad symptoms that are no longer apparent by the time a nurse comes in.

Risk #3: Some problems may be omitted if intervention isn’t necessary.

Say, for example, that a patient is experiencing some discomfort while sitting. There might not be anything that can be done to address the problem, but it’s still an important issue for the patient’s care team to be aware of.

In addition to these potential pitfalls, consider the following case study in which the CBE technique wasn’t properly implemented by each nurse who cared for the patient.


Charting By Exception in Nursing: A Case Study

A young mother was in the hospital for neurosurgery to remove a tumor behind her ear. She left surgery and went directly to radiology for post-op film and then to the medical-surgical floor, where patients are sent to recover from evening surgery. On the med-surg floor, nurses are told to do neuro assessments on the patient every two hours.

A typical patient who had this type of surgery for an acoustic neuroma would have normal symptoms of headaches, nausea, and pain. She presented with these symptoms, but on day four post-op, nurses found the patient in a vegetative state. She had a very small brain bleed that was missed by the radiologist immediately after surgery, and it had been left unaddressed for the past four days.

What went wrong? Attorney Linda M. Stimmel represents hospitals and other healthcare providers in Dallas and Louisville, Kentucky. She recalled this case, which ultimately involved the various methods of notes taken by three different nurses throughout the patient’s stay.

  • Nurse 1 was a young, new nurse who followed the hospital’s CBE policy to a T. She noted normal signs and symptoms on the patient, who didn’t appear or report to be suffering from anything outside the norm. She did a full assessment with details on the patient in the morning, then every two hours throughout her shift she’d arrive for another assessment. However, with no change, she didn’t write anything new.
  • Nurse 2 was an older, more experienced nurse who didn’t believe in CBE. She wrote a full, detailed assessment every two hours.
  • Nurse 3 did a hybrid of the first two nurses, making a complete first assessment, and then writing “no change” every two hours thereafter.

The only thing written from Nurse 1 was her very first assessment at 7 a.m., as she noted no changes throughout her shift. So, because the other two nurses didn’t fully employ CBE and had something written every two hours regardless of change, the jury believed Nurse 1 never went back to check on the patient.

Stimmel says the medical industry is like a pendulum when it comes to CBE. Organizations use it, but then they decide they don’t like it and go back to full narrative charting. That is, she adds, until they decide that’s getting to be too much work and revert to the more abbreviated CBE method. For Stimmel, either way is fine; the key is consistency.

Attorneys can defend CBE, Stimmel says, as long as everyone within a given organization is trained the same way to follow the same policies and procedures. Staff must be trained and re-trained to keep their understanding of CBE fresh. Ultimately, Stimmel says, CBE is a “good deal” for a nurse who would rather spend more time with patients than she would taking lengthy, repetitive notes.


How To Help Prevent Charting Errors

Backup documentation can save a case, Stimmel says. If Nurse 1 had more documentation, such as blood test results or vitals, she would have had a stronger case with documents to back up her normal findings.

Stimmel says that because doctors rarely have the time to read nurses’ notes, they typically learn about what has occurred with their patients by oral report from the nurse. For that reason, many nurses find it beneficial to have a separate chart just for notes. This might be where they keep medication records to detail time and dosage, or any kind of important information they may need to pass along to a concerned doctor.

Even with CBE, a patient’s chart should give the complete rundown of their condition, following a flow sheet for normal findings and detailing any and all deviations. Stimmel says CBE is “not the enemy,” but to properly execute it, the entire organization must be on board.

Follow these tips for using the CBE technique so you can keep everything running smoothly.

Tip #1: Stay on top of training.

Every staff member must be fully trained and consistently re-trained on the facility’s CBE policies.

Tip #2: Create visual reminders.

Normal patient standards and facility processes should be wholly understood by all staff. Visual reminders around the workplace can help keep this top of mind.

Tip #3: Always have a backup plan.

This could mean backup in the form of other staff who can help double-check charting, or it could refer to backup documents, such as lab or test results.


Final Thoughts

Although we said this earlier, it bears repeating: Every facility has its own standards for defining what’s “normal” for a patient. Before you begin using a technique like CBE, make sure you’re well-versed in your organization’s guidelines and standards of care. And, if available, make sure you receive any training offered on your employer’s CBE policies and procedures. Taking these preliminary steps could help you to avoid making charting errors while also allowing you to provide your patients with the highest quality care possible.

The views expressed in this article are those of the author and do not necessarily reflect those of Berxi™ or Berkshire Hathaway Specialty Insurance Company. This article (subject to change without notice) is for informational purposes only, and does not constitute professional advice.

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