9.12 : 记录方法V：按例外记录表格

The charting by exception or CBE system differs from traditional documentation methods.

Rather than recording every detail, CBE records only significant or abnormal findings.

CBE includes well-defined standards of practice and predefined statements for the nursing documentation of "normal" body system findings.

These 'normal' findings, termed "within defined limits" or WDL, outline the criteria for assessing each body system's "normal" state.

Nurses choose a WDL statement or other statements from a drop-down menu to describe abnormal results or findings that differ from the WDL definition.

The CBE method offers several benefits, such as improved standardized assessment, prompt bedside recording, efficient interprofessional communication and cost-effectiveness.

Using this approach reduces documentation time, allowing more time for direct patient care. In addition, CBE eliminates duplication in charting.

Although the CBE method has benefits, it requires the creation of specific protocols or standards.

Also, nurses unfamiliar with charting by exception may overlook vital information and miss critical data.