The nurse is documenting care in a client's medical record. The nurse provides narrative documentation only for abnormal assessment findings. Based on this information, which type of charting is the nurse using?
A)Computerized documentation
B)Charting by exception (CBE)
C)SOAP charting
D)Focus charting

Question

Quizplus · Accepted Answer

A)Charting by exception (CBE)is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE. Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Focus charting is organized into data, action, and response sections, referred to as DAR. SOAP charting is a way to organize data and information in the client's record: S indicates subjective data, O indicates objective data, A indicates assessment, and P indicates plan of care.
B)Charting by exception (CBE)is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE. Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Focus charting is organized into data, action, and response sections, referred to as DAR. SOAP charting is a way to organize data and information in the client's record: S indicates subjective data, O indicates objective data, A indicates assessment, and P indicates plan of care.
C)Charting by exception (CBE)is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE. Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Focus charting is organized into data, action, and response sections, referred to as DAR. SOAP charting is a way to organize data and information in the client's record: S indicates subjective data, O indicates objective data, A indicates assessment, and P indicates plan of care.
D)Charting by exception (CBE)is a documentation system in which only abnormal or significant findings or exceptions to norms are recorded. Flow sheets, standards of nursing care, and bedside access to chart forms are all incorporated into CBE. Computerized documentation is a way to manage the volume of information required in a client's chart, and different systems may include a variety of setups and programs. Focus charting is organized into data, action, and response sections, referred to as DAR. SOAP charting is a way to organize data and information in the client's record: S indicates subjective data, O indicates objective data, A indicates assessment, and P indicates plan of care.

The Nurse Is Documenting Care in a Client's Medical Record