charting by exception


charting

 [chahrt´ing] the keeping of a clinical record of the important facts about a patient and the progress of his or her illness. The patient's chart most often contains the history; laboratory reports; list of medications; results of physical examinations, consultations, and special diagnostic tests; treatments of the health care team; any problems; and the patient's response to interventions and treatment. See also problem-oriented record.charting by exception a method of charting designed to minimize clerical activities; a notation is made only when there is a deviation from the baseline or expected outcome, or when a procedure or expected activity is to be omitted.

char·ting by ex·cep·tion

(chahrt'ing ek-sep'shŭn) A method of documentation based on established standards of practice, for which reason only exceptions to these standards are documented.