Review Charting By Exception (CBE)

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Charting By Exception (CBE)

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Total Questions : 5

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Question 1:

A nurse is using the CBE system to document the care of a client with pneumonia.

Which of the following actions should the nurse take?

A. Record the client’s vital signs on a flow sheet every 4 hours. B. Write a narrative note for every nursing intervention performed. C. Document the client’s response to antibiotics in the progress notes. D. Refer to the agency’s standards of care for routine procedures.

Answer and Explanation

Choice A:

Charting by exception (CBE) documentation is a system that only requires the nurse to document deviations from predefined norms or standards of care.

Choice B:

The nurse only needs to record routine data such as vital signs on a flow sheet and does not need to write a narrative note for every nursing intervention performed

Choice C:

Choice D:

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Question 2:

A nurse is reviewing the EHR of a client who is admitted for chest pain.

Which of the following information should the nurse expect to find in the EHR?

(Select all that apply.).

A. The client’s medical history and current medications. B. The results of the client’s electrocardiogram and cardiac enzymes. C. The discharge plan and teaching for the client and family. D. The variances from the critical pathway for the client’s diagnosis. E. The names and contact information of the case management team.

Answer and Explanation

Choice A:

The client’s medical history and current medications, and the results of the client’s electrocardiogram and cardiac enzymes are information that the nurse should expect to find in the EHR of a client who is admitted for chest pain.These are essential components of an EHR that provide comprehensive health information about the patient, such as their diagnosis, treatment, and progress.

Choice B:

Choice C:

The discharge plan and teaching for the client and family are not part of the EHR until the client is ready to be discharged.They are not relevant for a client who is newly admitted for chest pain.

Choice D:

The variances from the critical pathway for the client’s diagnosis are not part of the EHR, but rather a quality improvement tool that monitors the deviations from the expected outcomes and interventions for a specific diagnosis.

Choice E:

The names and contact information of the case management team are not part of the EHR, but rather a communication tool that facilitates coordination of care among different providers and organizations.

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Question 3:

A nurse is caring for a client who is on a critical pathway for a total hip arthroplasty.

The nurse notices that the client has developed a wound infection on postoperative day 3.

What should the nurse do next?

A. Notify the surgeon and document the wound infection as a variance. B. Change the dressing and document the wound infection as an exception. C. Continue the care plan and document the wound infection as an expected outcome. D. Discontinue the critical pathway and document the wound infection as a complication.

Answer and Explanation

Choice A:

Notify the surgeon and document the wound infection as a variance.A variance is a deviation from the expected course of care or outcome in a critical pathway.A wound infection is an example of a variance that can affect the patient’s recovery and length of stay after a total hip arthroplasty (THA).

The nurse should notify the surgeon to initiate appropriate treatment and document the infection as a variance in the patient’s record

Choice B:

Changing the dressing alone is not sufficient to treat a wound infection.

The nurse should also notify the surgeon and document the infection as a variance.

Choice C:

A wound infection is not an expected outcome of THA.It is a complication that can increase the risk of implant failure, sepsis, and revision surgery.

Choice D:

Discontinuing the critical pathway is not necessary or appropriate for a wound infection.The critical pathway is a guideline for optimal care that can be modified according to the patient’s condition and needs.

The nurse should follow the critical pathway as much as possible and document any variances.

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Question 4:

A nurse is preparing to discharge a client who has been on a case management model of care.

The nurse wants to evaluate the effectiveness of the care provided.

Which of the following statements should the nurse use?

A. “Did you receive quality care during your stay?.”. B. “How satisfied are you with your recovery process?.”. C. “Did you achieve your expected outcomes within the planned time frame?.”. D. “How well did you understand your discharge instructions?.”.

Answer and Explanation

Choice A:

It is too vague and subjective.

Asking the client if they received quality care during their stay does not specify what aspects of the care were satisfactory or not, or how they relate to the case management model.

Choice B:

It is also too vague and subjective.

Asking the client how satisfied they are with their recovery process does not indicate what goals or outcomes were set or achieved, or how they were influenced by the case management model.

Choice C:

This statement is the best way to evaluate the effectiveness of the case management model of care, which is a plan that describes how to provide comprehensive and effective care to clients with different health needs and situations.It involves steps such as assessing, planning, implementing, coordinating, monitoring, and evaluating the care.By asking the client if they achieved their expected outcomes within the planned time frame, the nurse can measure the quality, satisfaction, and cost-efficiency of the care provided.

Choice D:

It is too narrow and specific.

Asking the client how well they understood their discharge instructions does not reflect the whole process of the case management model, which involves more than just discharge planning.

It also does not measure the effectiveness of the care in terms of outcomes or cost-efficiency.

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Question 5:

A nurse is using a computer terminal at the client’s bedside to document care immediately after it is given.

Which of the following advantages does this method of documentation have?

A. It reduces transcription errors and improves accuracy. B. It allows access to multiple sources of information at once. C. It enhances communication and collaboration among health care team members. D. It saves time and increases efficiency for the nurse.

Answer and Explanation

Choice A:

It is not specific to bedside documentation.

Any method of documentation can reduce transcription errors and improve accuracy if done properly.

Choice B:

It is not an advantage of bedside documentation per se, but rather an advantage of electronic documentation in general.

Choice C:

It is not exclusive to bedside documentation.

Communication and collaboration among health care team members can be enhanced by other means, such as huddles, rounds, or handoffs.

Choice D:

Bedside documentation is the process of recording clinical information at the point of care, using paper or electronic formats.

This method of documentation has several advantages, such as:.

• It reduces transcription errors and improves accuracy, as the information is recorded directly from the source and not from memory or notes.

• It allows access to multiple sources of information at once, such as electronic health records, lab results, medication orders, etc.

• It enhances communication and collaboration among health care team members, as the information is shared in real time and can be accessed by authorized personnel.

• It saves time and increases efficiency for the nurse, as it eliminates the need to leave the patient’s bedside to document care or to transfer information verbally.This also allows more direct time with patients and improves patient satisfaction.

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Charting By Exception (CBE)

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