Methods of Documentation V: CBE

Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.

In CBE, healthcare professionals establish predefined standards of practice that define what constitutes a "normal" state for various aspects of patient care, such as vital signs, physical assessments, and other clinical parameters. These standards, often referred to as "within defined limits" (WDL), serve as guidelines for determining whether a patient's condition falls within an expected range of values or if there are deviations that require attention.

Nurses select a WDL statement or other statements from a dropdown menu to articulate abnormal results or findings that deviate from the WDL definition—enhancing word choice, structure, readability, and eloquence while preserving the original meaning.

When documenting patient care using CBE, healthcare providers typically chart only when there is a deviation from the established norms or a significant change in the patient's condition. Instead of documenting routine or expected findings, such as typical vital signs or unremarkable physical exam findings, providers report deviations from the norm, abnormalities, interventions, and responses to treatment.

The benefits of charting by exception include:

• • Improved efficiency: By focusing documentation efforts on abnormal findings, CBE reduces the time and effort required for charting routine information.
• • Enhanced clarity: CBE helps to highlight significant deviations from normalcy, making it easier for healthcare providers to identify areas of concern and take appropriate action.
• • Standardization: Establishing predefined standards of practice promotes consistency in documentation across healthcare settings and among different providers.
• • Cost-effectiveness: By reducing the time spent on documentation, CBE can lower administrative costs associated with record-keeping.

While CBE can enhance efficiency and streamline documentation, it may only suit some situations or patients. Critics argue that relying solely on CBE may overlook important details or subtle changes in a patient's condition. Healthcare organizations must balance the benefits of CBE with comprehensive documentation for patient safety and quality care.