The nurse is documenting client care on flow sheets that identify abnormal assessment findings. Which type of documentation system is the nurse using?

Question

1. Computerized documentation
2. Focus charting
3. SOAP charting
4. Charting by exception

Answer 1

Correct Answer: 4
Rationale 1: 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.
Rationale 2: Focus charting is organized into data, action, and response sections, referred to as DAR.
Rationale 3: 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.
Rationale 4: 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.