What are the three key elements of Charting by Exception (CBE) as described in the chapter?
The three key elements of Charting by Exception (CBE) are flow sheets, standards of nursing care, and bedside access to chart forms.
Charting by Exception (CBE) is a documentation system that focuses on recording only abnormal or significant findings. The three key elements of CBE include: 1. **Flow Sheets**: These are used to document routine assessments and interventions, such as vital signs or skin assessments, allowing for quick reference and easy identification of deviations from the norm. 2. **Standards of Nursing Care**: These standards are predefined by the healthcare facility and serve as a baseline for care. Routine care is documented by checking off these standards, and only exceptions are described in detail. 3. **Bedside Access to Chart Forms**: This ensures that documentation can be done immediately at the point of care, reducing errors and the need for transcription from separate notes.
Key points
- Flow sheets are used for quick documentation of routine care.
- Standards of nursing care provide a baseline for documentation.
- Bedside access to chart forms allows immediate recording.
- CBE focuses on documenting only exceptions to normal findings.
- Routine care is documented by checking off predefined standards.
Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice
Berman, Audrey Frandsen, Geralyn Snyder etc.
Tenth edition · Pearson Education Limited