Documentation

Charting by Exception Format, Strengths and Weaknesses

Strengths

Noted strengths of the Charting by Exception documentation format include the following:

• Sets standards for assessment and care
1. Has guidelines printed on the form
2. Promotes uniform nursing practice
• Makes abnormal trends obvious
• Highlights abnormal data and makes it retrievable
• Isn’t obscured by normal data
• Reduces charting time
• Requires fewer pages

Weaknesses

Noted weaknesses of the Charting by Exception documentation format include the following:

• Progress notes
1. May be very brief since they depend a lot on flow sheets
2. Have large blank areas
3. May intentionally omit routine care
• CBE notes can’t be used in multidisciplinary charting
• They take a major time commitment to develop
• They require in-depth training
• All stages of the nursing process are not always evident—especially nursing judgments or evaluations
• Isolated or unexpected events aren’t documented
• The care plan isn’t always revised
• Preventive/wellness issues aren’t addressed
• Predictable defined outcomes are required
• It can be difficult to ensure completeness
• It’s difficult to automate this charting format
• This format also includes all the problems inherent in the SOAP format
• Users of this format report problems with double documentation
1. Information repeated on nurses’ and doctors’ orders, flow sheets, and SOAP notes
2. Subjective and objective information repeated on flow sheets
3. The assessment and plan of the SOAP notes may be on the plan of care

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