Charting by ‘exception’ is a clinical documentation practice popularized in the 1980’s to improve the clarity of clinical notes, focus attention on clinically important information, improve signal-to-noise ratios, and reduce clinician information burdens. The record emphasizes significant findings or ‘exceptions’ to a predefined normative state.
To the extent that clinical documentation serves clinical care – thinking instead of scribing – then exception charting can improve the accuracy of diagnosis, help prevent error and improve the patient experience by ensuring that high-value information is front-of-view.
The prime purpose of Connect Care charting is to support high-quality, safe and efficient health care. Accordingly, technical, procedural and cultural supports for exception charting are important to the design of the Connect Care clinical information system (CIS). Indeed, the design process can help specialty groups define normative datasets and express these in clinical information system charting tools. And the act of ratifying these norms can help establish a safe exception charting culture.
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