The nurse is documenting care in the medical record. The nurse provides narrative documentation only for abnormal assessment findings. Which type of charting is the nurse using based on this example?
A) Computerized documentation
B) Charting by exception (CBE)
C) SOAP charting
D) Focus charting
Answer: B
Charting by exception (CBE) is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE. Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Focus charting is organized into data, action, and response sections, referred to as DAR. SOAP charting is a way to organize data and information in the client's record: S-subjective data; O-objective data; A-assessment; P-plan.
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