Help Please, Charting by exception

It means the nurse does not write narrative notes unless something "unusual" occurs. (Patient's Sats 90% on room air. Applied nasal cannual with 2 LPM O2. MD notified). I caution you to not be strict with this, as it may be hard to justify 24 hr. nursing care when the patient only received a few tiny nursing notes. You need to learn how to not be wordy, but demonstrate the need for nursing care.

Hi, All,

I'm the author of the two books on Charting By Exception, so I feel qualified to respond to this post. I read many of the responses and want to be sure that everyone understands the basics of CBE. There are 3 key principles:

1. There are baseline definitions of norms, so when you use a checkmark, asterisk, or arrow, you know what you are referring to. These are either written in your documentation policy or are listed as reference text on your computerized documentation system so that you can always speak to what you meant when you used the symbol. The * symbol actually means that there WAS an exception to the norm and you're SUPPOSED to write a narrative note that describes the deviation from norm. One poster in this community stated "when something unusual happens, CBE goes out the window." That is totally wrong! If you follow the CBE guidelines, you are very clearly told how to document the changes in the patient's condition using narrative notes or selections from computerized pick-lists with additional remarks made in narrative form in the "comments section." One other poster also CORRECTLY noted that using CBE does not exonerate you from documenting teaching and changes in the patient's condition. Make sure that these issues are addressed according to your documentation policy.

2. When the nurse charts the accountability timeframes, he/she is also indicating that all standards and protocols were followed. Again, the documentation policy needs to state this. I've been an expert witness on legal cases where the documentation policy was inadequate because policy designers didn't really read the CBE books, they just claimed that they didn't chart anything because nothing was unusual and they thought this was Charting By Exception (WRONG!) or they adapted an "idea that they heard about" (usually the use of symbols without the defined norms specified) and that caused problems in their institution. Do it right and it always works!

3. Chart as you go! Documentation is always more exact, complete, and accurate if the nurse does "real-time" charting. If you're working in an electronic charting system, make sure that the date/time on the data you're entering is the time you want it to be! Some systems have defaults set to "today" and "now", yet the nurse may be recording a finding that happened in the past. The nurse has to be diligent to assure that his/her documentation reflects real-time charting, either by doing it as they go, or by staying vigilant and adjusting the dates and times to the appropriate ones.

I'd like to make one additional comment. In our second book, we wrote about the 6 key features of exception-based charting systems. The one that I consistently see missed is the need to have ongoing auditing done and remedial education or performance evaluations done that include adherence to documentation policies.

You can't just throw out forms with symbols and no defined norms, you can't expect nurses to know that they gave care according to standards unless you define for them where those standards are documented and what they include and you can't expect nurses to remember details of complex care sequences of events if you don't provide them with the necessary tools to chart as you go like either bedside paper charts or computers on wheels or bedside computers.

Be sure all of the above are provided. Then, audit regularly. There are lots of nurses who are using good CBE systems across the country. Our second book actually quantifies that. But my experience also notes that there are always a small minority that don't do it right, don't bother to learn how to do it right, and then complain that the "system doesn't work." Make sure your system is sound, and then audit and coach these laggards to high performance. You'll like the results because the clinical record will truly reflect good nursing care and begin to highlight where nursing performance can improve to achieve excellent patient outcomes. And isn't that why we got into this profession in the first place?

Laura J. Burke, RN, PhD

I am a telephone triage nurse and we chart by exception. Can you tell me is CBE more of a legal liability in triage assessment. Besides your book is there references you would suggest to safe guard the telephone triage nurse?

No, it is not a legal liability in triage assessment, if the principles I outlined in my first post are followed. In fact, in our second book (there are 2, not 1), there are several examples of using CBE in the ED. Regarding your question, "besides your book is (sic) [are] there references you would suggest to safe guard the telephone triage nurse?" here's my response... and many other authors also have made this point: people don't sue you because of your charting. They sue you because you gave poor nursing care. To "safeguard the telephone triage nurse" (or any other type of nurse for that matter,) follow your standards of practice. Give quality nursing care. Assure that your documentation principles are comprehensive and consistently followed by all who use the documentation system, audit for compliance, and train for high performance. Ellen Murphy, a nurse attorney who wrote a column in AORN Journal and Janine Fiesta, another attorney who published an article on the issue several years ago, concluded that use of CBE in any setting was legal if it was done properly. Several other authors have documented use of charting by exception in their systems. I'm not going to summarize a lit search here. Anyone can do that by searching on "charting by exception" in CINAHL and you'll find the most pertinent articles. Be cautious in reading the early articles by Tammeallo (?sp) that cite the case from Puerto Rico. This was the earliest published legal case where the defense attorneys had "heard about CBE" and claimed that that was what the nurses were doing. Mary Wolverton, our attorney, contacted the Puerto Rican Hospital's defense attorneys who agreed that the nurses at that hospital had not read our books or journal articles, and had not followed any plan to create a charting by exception system. Mary Wolverton, Judy Murphy, and I wrote a letter to the editor outlining the flaws in all of the Tammeallo publications that were published. Our rebuttal will come up under Mary Wolverton's name if you do a lit search. Using CBE will streamline your documentation and save you time, which is a valuable commodity for a telephone triage nurse. Best wishes! Laura J. Burke, RN, PhD

Thank you so much for your time in answering this. Where are your books available for purchase, ( I can do online search. Again, Thank you for your time and reply. Maryann Kearns

Hi, Mary Ann,

Neither book is for sale any more. You can buy used books including ours through Amazon.com or Barnesandnoble.com. We also have at least 2 articles published and indexed in CINAHL. Search on Laura J. Burke, search on Judy Murphy. Combine the searches and you'll have our works in a short list. Laura J. Burke, RN, PhD

Management at the hospital where I work is cracking down on charting. We use charting by exception and it has been noted that a lot of times there is one note made at the beginning of the shift and nothing else. We still use paper charting, by the way. I am looking for ways to advise the younger nurses who work with me (I am in a charge nurse position) on the importance of noting the "exceptions"