Charting by Exception: Errors by Omission or The Efficient New Norm?

January 20, 2021 •

Charting by exception (CBE) is a shorthand method of documenting patient systems, using standard practices and patient norms to avoid charting redundancy and saving healthcare providers time and money. Using the Charting by Exception method, healthcare providers are required to chart only deviations from expected patient norms. The CBE systems can be different for every provider and is based on defined, clear normals. Exceptions to those differences are then documented by detail.

Electronic Health Records (EHR) and charting by exception go hand and hand. Since the transformational change caused by the COVID-19 pandemic, the push to digitize healthcare and treat more patients in less time is now a necessity. To have the ability to remotely communicate effectively about patient care is imperative. But is Charting by Exception (CBE) the solution?

(CBE) works by effectively reducing or eliminating repeat documentation of medical patient scenarios, reducing the redundancy and tedious documentation of expected patient health checks. The reduction in healthcare worker time spent per patient and a more concise medical record are part of the appeal. Charting by Exception’s assumptive process also allows for billing of physician time, increasing provider revenue. Does CBE’s efficiency increase the risk of errors? The answer is yes and no.

Charting by Exception and Risk Management

An American Medical Association 50-state survey of telemedicine outlines each state’s laws and guidelines for the establishment of a patient-physician relationship via telemedicine, but is following the rules enough when using shorthand medical documentation?

Many healthcare providers employ various CBE techniques and develop their own version of CBE Charting. These practice details can work to build a more accurate patient picture, based on the commonalities and differences of the particular patient group. Proponents of CBE argue that this process effectively reduces the risk of patient record errors.

The legal community has often taken a stance that if a medical event was not charted – it didn’t happen. This complicates the transition to the EHR and Charting by Exception. Documentation is key when addressing issues of accountability.

Other facilities implement various CBE Technique training programs to further increase accuracy of the chart.

In our new “hands off” world of COVID-19, the benefits of removing the nurse from the bedside are clear. Infection control and speed in documentation can both be improved using CBE, and telehealth visits have allowed for continuation of care during the pandemic, often employing Artificial Intelligence programs (AI) to do the core of the work.

Chronic care management (CCM) programs use CBE to assess patient changes during telehealth CCM visits allowing patients that would otherwise delay seeking treatment to be seen remotely. But according to a recent article in Healthcare IT News, we’re going to need some help. This illustrates the importance of CBE technique training to increase accuracy and reduce the disadvantages of shorthand patient care. Fine tuning our systems can lead to reduced errors and omissions, and reduced risk of malpractice allegations. We’re on the way but most healthcare workers agree that we’ve still got a long way to go.

Errors Under The RUG?

RUG (Resource Utilization Groups) is a patient classification system that uses categories to group nursing home residents according to their care and resources required. It is used by the Federal government to determine reimbursement levels for skilled nursing home facilities. Critics of CBE argue that CBE, by putting patients in a specific group, allow transient medical events to go uncharted and untreated.

For example, due to the shorthanded nature and assumptive properties of Charting by Exception, when Mrs. Smith suffers a transient lapse of clarity while the nurse is in the patient room and then Mrs. Smith returns to baseline moments later. No exceptions to her chart are entered. Days later, Mrs. Smith is found in another part of the facility, confused and injured. A lawsuit follows. Would nursing narratives have made a difference? Critics say “yes”.

Insurance Can Cover the Gaps

As legal experts, medical professionals and authority organizations work through this transition and the various stages of adoption, nurses and nurse practitioners can take a step to secure their own peace of mind and protect their efforts at work. An individual professional liability policy ensures you have a partner on your side if misinterpretation of charting causes a patient care scenario to go awry. Nurses can be named in a lawsuit individually alongside their employer. If that happens an individual professional liability policy can protect you.

Learn more about nurse and nurse practitioner insurance from NOW Insurance. Fill out our application today for an immediate quote. It’s likely more affordable than you think to get your  own insurance policy and have an expert to turn to if an unfortunate situation lands you in a lawsuit at work.

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