Implementing

Charting By Exception
A Method for Streamlining Documentation and
Making EPIC Work for Us

Katherine Reynolds, RN
Bobbi Schramek, MS, RN
Objectives
• Define Charting by Exception (CBE) and its
benefits
• Identify key components of CBE
• List at least 5 phases of CBE implementation
in a major healthcare organization
• Identify 3 challenges to CBE implementation
and the strategies to address these
challenges
• Identify 2 future considerations for CBE
implementation
Overview
• Skepticism versus Regulation
• Background for the project
• Definitions
• Benefits
• Planning
• Process Redesign
• Implementation
• Evaluation
• Ongoing Challenges
• Future
Skepticism against Charting by
Exception

• Regulatory concerns
– JCAHO
– IDPH
– CMS
• Legal concerns
– Malpractice defense
– Revocation of license
Regulatory Requirements

• Do not tell us how or where to document

• Do expect that our policies and standards

are supported by the documentation

• Do expect that the policies and standards

of the organization meet the regulatory
requirements
Legal Concerns

• Question of legality is same as regulatory

concern

• Must show that policies, standards and decisions

are supported by the documentation

• Those policies and standards meet the legal and

regulatory requirements.
Age Old Cultural Belief

The old adage, “If it wasn’t charted it wasn’t

done…” is clarified in CBE as “If
interventions, expected outcomes, and
patient responses weren’t charted using
symbols to reflect predefined norms-and
variances weren’t charted in detail--then, it
wasn’t done.”
Background of CBE Project
for ENH

• Epic implementation
• Practices of the paper world did not
translate to the electronic world
• Point of Care documentation mandate
• Super User Council concerns
Evaluation

• Literature Search on Charting by Exception

– Definition of CBE
– Benefits of CBE
CBE—What is it?

• Charting by exception (CBE) is a shorthand

method of documenting normal findings, based
on clearly defined normals, standards of practice,
and predetermined criteria for assessments and
interventions. Significant findings or exceptions
to the predefined norms are documented in
detail.
• Murphy and Burke, 1990
Benefits of CBE

• Standards allow for consistent quality of

care and documentation within
organization
• Abnormal findings are highlighted
• Repetitive documentation of routine care is
eliminated through use of standards
 documentation time
Evaluation and
Recommendations

• Analysis of current practice

• Task Force Formation
Phases of CBE
Implementation

• Task Force Formation and Education

• Analysis and Process redesign
• Foundation Work
– Definitions
– Policies
– Regulatory compliance
– Education Plan
Phases of CBE
Implementation

• Development of Epic content and build

– Flowsheets
– Care Plans
• Implementation
• PI Plan for ongoing evaluation and
performance management
Task Force Formation and
Education

• Multidisciplinary representation on the task

force
• Education of task force
– CBE definition and key components
– Support materials for successful
implementation
• Charge of the task force
Analysis and Process Redesign

• Key components of CBE

• ENH analysis for key components
• Determination of what was needed
• Change the culture of “If you didn’t chart it,
it wasn’t done”
• Change documentation process
 Detailed Charting by
Charting Exception
Normal
Findings  
Abnormal
Findings  
Interventions
Completed  
Intervention
Variances  
Key Components of CBE

• Standards and nomenclature

• Purpose specific documentation tools
• Point-of-care accessibility of
documentation tools
• PI plan for ongoing evaluation of staff
compliance
Foundation Work

• Define Charting by Exception for ENH

• Develop documentation policies to support
CBE
• Review for regulatory compliance
• Education Plan
– Content
– Timeline
– Personnel
Epic Content and Build

• WNL definitions

• Custom list and definition comparison

• Assessment WNL row

• Restructure of flowsheet templates

Implementation of CBE

• Communication with all stakeholders

– Superuser Advisory Council
– Clinical Operations Council
– EPICcare Meeting
– Staff Nurse Advisory Board
• Staff education
• Go-live of WNL flowsheets
Performance Improvement
Plan

• Audit tool

• Compliance audit schedule

Performance Improvement Data

• Staff re-education
 PercentageofofAssessments
Percentage Assessmentsusing
using WNL
WNL Correctly
Correctly
Comparison by
Comparison by Facility
Facility
50%
EV HP ENH
40%

30%
84 / 199 GB 121 / 299
20%
30 / 70

10% 7 / 30
0%
January, 2005
Performance Improvement Data

• Staff re-education

• Validation of policies related to WNL

• Validation of build
Challenges to CBE
Implementation

• RN understanding of CBE

• Culture changes

• Row sharing
Future Considerations

• Culture change

• Expanding scope of CBE without losing

larger picture
Contact Information

Katherine Reynolds, RN
kreynolds@enh.org
847-570-2999

Bobbi Schramek, MS, RN

bschramek@enh.org
847-570-2459