{"id":138421,"date":"2024-09-14T15:12:50","date_gmt":"2024-09-14T15:12:50","guid":{"rendered":"https:\/\/learnexams.com\/blog\/?p=138421"},"modified":"2024-09-14T15:12:52","modified_gmt":"2024-09-14T15:12:52","slug":"a-nurse-is-documenting-client-care-including-only-unexpected-findings-related-to-the-clients-condition","status":"publish","type":"post","link":"https:\/\/www.learnexams.com\/blog\/2024\/09\/14\/a-nurse-is-documenting-client-care-including-only-unexpected-findings-related-to-the-clients-condition\/","title":{"rendered":"A nurse is documenting client care including only unexpected findings related to the client’s condition"},"content":{"rendered":"\n

A nurse is documenting client care including only unexpected findings related to the client’s condition.
Which of the following documentation methods is the nurse utilizing?
A.
Charting by exception (CBE).<\/p>\n\n\n\n

B.
Focus charting (DAR).<\/p>\n\n\n\n

C.
Problem-oriented medical record (POMR).<\/p>\n\n\n\n

D.
SOAP documentation.<\/p>\n\n\n\n

The correct answer and Explanation is :<\/strong><\/mark><\/p>\n\n\n\n

The correct answer is A. Charting by Exception (CBE)<\/strong>.<\/p>\n\n\n\n

Explanation:<\/strong><\/p>\n\n\n\n

Charting by Exception (CBE)<\/strong> is a documentation method used in nursing where only the deviations from the expected norms or standard procedures are documented. This approach streamlines the documentation process by focusing on significant or unexpected findings rather than recording every routine observation.<\/p>\n\n\n\n

In CBE, the nurse documents only those aspects of patient care that deviate from the established standards or expectations. For example, if a patient’s vital signs are stable and within normal limits, this might not be recorded in detail. However, if there is an abnormal reading, such as a sudden spike in blood pressure or a change in neurological status, the nurse would document these unexpected findings. This method allows for more efficient documentation and helps to highlight critical changes in the patient\u2019s condition that require attention.<\/p>\n\n\n\n

The main benefits of CBE include reducing the amount of repetitive documentation, making it easier to spot significant changes in a patient’s condition, and allowing for a more focused review of critical data. However, it also requires that the standards for normal and expected findings are well-established and consistently followed, as any deviations must be clearly understood and recognized.<\/p>\n\n\n\n

Other documentation methods include:<\/p>\n\n\n\n