Charting By Exception (CBE)

CBE is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded.

Key Elements of Charting By Exception (CBE)

• Flow sheet: Examples include a graphic record, fluid balance record, daily care record, client teaching record, client discharge, and skin assessment record.
• Standards of nursing care: Documentation by reference to the agency's printed standards of nursing practice eliminates much of the repetitive charting of routine care.
• 

Bedside Access to Chart Forms

• In the CBE system, all flow sheets are kept at the client's bedside to allow immediate recording.

• Computerized Documentation: Electronic Health Record (EHR)

• EHR was developed to manage the huge volume of information required in contemporary healthcare. It stores the client's database, new data, revised care plans, and documents client progress. Some institutions have a computer terminal at each client's bedside to enable the nurse to document care immediately after it is given.

Case Management

Case Management is a model that emphasizes quality, cost-effective care delivered within an established length of stay. It uses a multidisciplinary approach to planning and documenting client care. Using critical pathways helps identify the expected outcomes for each day of care. Variances are deviations from what was planned on the critical pathways, such as elevated temperature or impaired skin integrity.