Is Charting by Exception Still a Defensible Documentation System in the Electronic Health Care World?

3/30/13 - Charting by exception continues to be a viable documentation method used by health care systems to streamline clinician documentation.  Now that computerized charting systems exist, organizations must request that all elements be built into the "model" or "starter" forms of these Electronic Health Records.  These include reference documentation of "within defined limits" (WDL) or "within normal limits" (WNL) parameters and their definitions.  In addition, they include documentation by the clinician that the "care was delivered according to standard" and a definition of which standards are being referenced.  Organizations should maintain historical archives of what the WDL definitions, standards, and reference documents are at any point in time so that these can be retrieved if any case should undergo a legal review.
Laura J. Burke, PhD, RN-BC, FAAN