Charting by Exception (CBE)
Charting by exception (CBE) is a documentation approach in which the organization and its documentation system define expected findings in advance, and findings that differ from those defined standards are documented in detail. Dosage Calcs does not define what is normal; CBE rules, standards and required entries vary by organization.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
CBE aims to reduce repetitive charting. It only works when the organization has clearly written standards, and when the nurse actually assesses each item. Marking "within defined limits" means the nurse assessed it and it met the written standard; it is never a shortcut for items not assessed.
When this may be used
- Facilities with written definitions of expected findings, usually in flowsheets or EHR assessment screens.
- Only with the organization's approved definitions; the meaning of "WDL" differs from one facility to another.
- Many facilities combine CBE flowsheets with narrative or focus notes for exceptions.
- CBE requirements are not universal. Some organizations still require specific entries even when findings meet the standard; follow your organization's policy.
- Never assume an undocumented finding was normal unless the organization's documentation system specifically establishes that convention.
- This guide and its template are educational and cannot replace an organization's flowsheet, EHR or documentation policy.
Components
Defined standards
Written criteria for each system.
What belongs here
- The organization's written definitions
What does not belong
- Your own personal definition of normal
Assessment against standards
The nurse assesses each item.
What belongs here
- Marking an item as meeting the standard only after assessing it
What does not belong
- Marking items not assessed
Exception documentation
Detail for anything that differs.
What belongs here
- Specific description of the abnormal finding, actions and response
What does not belong
- A vague "abnormal" with no description
Short fictional example
- Neurological
- Within the facility's defined limits (assessed 0800).
- Skin
- Exception: 2 cm × 1 cm reddened area on left heel that does not blanch. Heels floated on pillow at 0810.
More detailed fictional example
- Flowsheet
- Neurological, cardiovascular and gastrointestinal: assessed and met the facility's defined standards at 0800.
- Respiratory (exception)
- Expiratory wheezes heard in both upper lobes at 0800. Respiratory rate 22. SpO2 93% on room air. Patient states "I feel a bit tight."
- Action
- Scheduled nebulized bronchodilator given at 0805 per order.
- Response
- 0835: wheezes decreased in both upper lobes; respiratory rate 18; SpO2 95% on room air. Patient states "breathing easier."
Annotated example
Notes on the detailed example above:
assessed and met the facility's defined standards
— Only systems actually assessed are marked.Expiratory wheezes heard in both upper lobes
— Exceptions get specific, descriptive detail.0835: wheezes decreased…
— The response to care is documented with time.
Common mistakes
- Marking every system "WDL" without assessing it.
- Assuming another facility's definition of WDL applies.
- Writing "abnormal" without describing the finding.
- Not documenting follow-up for an exception.
Good vs poor documentation
Weaker (fictional)
Skin: abnormal.
Stronger (fictional)
Skin: 2 cm × 1 cm reddened area on left heel that does not blanch.
Why: An exception needs a specific description.
Blank educational template
Charting by exception — educational template: Charting by exception relies on predefined standards or expected findings established by the organization and its documentation system. This educational template does not define what is 'normal' and should not replace facility-specific documentation requirements. Prompts only; nothing is prefilled.
- Assessment / Documentation Period
- [Document according to the organization's established assessment and documentation requirements.]
- Established Standard / Baseline
- [Use the organization's defined standards or normal findings. Do not invent or assume a universal normal baseline.]
- Exceptions / Abnormal Findings
- [Document relevant findings that differ from the organization's established standard or expected finding.]
- Focused Assessment Details
- [Document additional assessment information related to the exception when applicable.]
- Nursing Actions / Interventions
- [Document actions actually performed.]
- Communication / Notification
- [Document communication or notification that actually occurred when applicable.]
- Patient Response / Reassessment
- [Document the observed response or reassessment when applicable.]
- Additional Documentation
- [Document other relevant information required by the organization's policy or documentation system.]
Practice this format
Related documentation guides
Sources
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.