Discuss the purpose and give an example of charting by exception in the patient's medical record.
What will be an ideal response?
Charting by exception (CBE) is an abbreviated approach to medical charting that involves recording only unusual or out-of-the-ordinary events. The CBE format includes a standardized nutritional care plan. After the initial charting of the care plan, only significant data and/or unanticipated responses to the proposed plan should be included in the record. In most CBE formats, a flowchart is used to document assessments and interventions. An asterisk (*) indicates an abnormal finding on an assessment or an abnormal response to an intervention. The findings are explained in the comments section of the form. An example of CBE might be documenting on a patient who has been vomiting; the dietitian fills out the flow chart and then writes an asterisk in the GI section. In the notes, the dietitian may then write, “* Pt. has vomited three times this morning…" and go on to explain the cause and effects of the situation.
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