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Charting By Exception (CBE)
Charting By Exception (CBE) ( 5 Questions)
A nurse is using the CBE system to document the care of a client with pneumonia.
Which of the following actions should the nurse take?
Charting by exception (CBE) documentation is a system that only requires the nurse to document deviations from predefined norms or standards of care.
The nurse only needs to record routine data such as vital signs on a flow sheet and does not need to write a narrative note for every nursing intervention performed
Record the client’s vital signs on a flow sheet every 4 hours. This is because charting by exception (CBE) documentation is a system that only requires the nurse to document deviations from predefined norms or standards of care.
Therefore, the nurse only needs to record routine data such as vital signs on a flow sheet and does not need to write a narrative note for every nursing intervention performed (B), document the client’s response to antibiotics in the progress notes ©, or refer to the agency’s standards of care for routine procedures (D). These actions are unnecessary and time-consuming in CBE documentation, as they would duplicate information that is already available in the electronic health record (EHR) or the agency’s policies. CBE documentation is designed to decrease the amount of time required to document care and to improve the quality and accuracy of patient records.