# Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric ward that still uses paper records. Nurses write problem-oriented notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), and routine assessments are recorded on flow sheets using charting by exception. Under the ward's charting by exception system, what does the nurse write out in the notes?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630151  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 24-year-old man with schizophrenia is in his second week on a psychiatric ward that still uses paper records. Nurses write problem-oriented notes in SOAPIE format (Subjective, Objective, Assessment, Plan, Intervention, Evaluation), and routine assessments are recorded on flow sheets using charting by exception.

Under the ward's charting by exception system, what does the nurse write out in the notes?

## 보기

1. Only findings outside the ward's defined norms **✔ 정답**
2. Every assessment finding, including normal ones
3. Only the interventions and the client's response
4. Only findings that need a change in the care plan

**정답: 1**

## 해설

Charting by exception records only deviations from established, written norms; normal findings are assumed to meet the standard and are marked on the flow sheet. The system works only when the norms are clearly defined and known to every nurse.

## 심화 해설

Core concept

Charting by exception (CBE) is a documentation system that records only significant findings or exceptions to pre-established written norms; all normal or expected assessment data are considered to meet the standard and are simply marked as within normal limits on the flow sheet [2]. In a psychiatric ward using paper records, the nurse writes in the narrative notes only those findings that fall outside the defined norms—an abnormal mental status change, a new side effect, a fall, or a refusal of care. Routine findings such as “affect stable, no hallucinations, vital signs within normal limits” are not written out in longhand because the flow sheet already indicates they were assessed and found normal.

Why this works in clinical practice

The system is built on a simple assumption: if a finding is not charted as an exception, it is understood to be within the defined normal range. This is why the standards or norms must be clearly written, specific to the unit and patient population, and known to every nurse. For a client with schizophrenia, the ward’s norms might include “no aggressive behavior,” “no auditory hallucinations reported,” “sleeps at least 6 hours,” and “attends at least one group activity per shift.” The nurse checks these on the flow sheet. Only when the client deviates—for example, reports new command hallucinations or becomes agitated—does the nurse write a narrative SOAPIE note describing the exception, the intervention, and the response.

Watch out! The nurse does not write out every normal finding, because that would defeat the purpose of the system and create redundant, time-consuming documentation [1][3]. The nurse also does not document only interventions and responses, because the abnormal finding itself must be described to justify the intervention. And the nurse does not limit notes only to findings that require a change in the care plan—an exception may be significant and require documentation even when the current plan remains appropriate, such as a single episode of breakthrough anxiety that resolves with PRN medication.

Efficiency and patient safety

The rationale for CBE is well documented in the literature. One medical center found that nurses spent 2.5 hours per shift documenting before CBE was integrated with a clinical pathway; afterward, charting time dropped to 0.82 hours per shift [3]. In home care, CBE reduced documentation time so that nurses could devote more hours to hands-on care without compromising patient care [1]. In perianesthesia settings, adapting CBE principles condensed documentation, decreased time spent on documentation, and diminished variance in documentation quality . These benefits apply equally to an inpatient psychiatric ward: less time writing repetitive normal findings means more time for therapeutic interaction, observation, and de-escalation.

Key point! The safety of CBE depends entirely on the quality of the written norms. If the norms are vague or if nurses do not know them, a clinically significant change may be missed because it was never written down. In a psychiatric setting, this is especially important because subtle changes in affect, thought process, or behavior can signal impending relapse or violence. Therefore, the nurse must know the unit’s defined norms for a client with schizophrenia, mark the flow sheet accurately, and write a narrative note only when the client’s status deviates from those norms [2].References (research sources)

- [1]Charting by exception.Research articleParker CS (1997)

- [2]Charting by exception: a solution to the challenge of the 1996 JCAHO's nutrition care standards.Research articleCharles EJ (1997) · DOI: 10.1016/s0002-8223(97)00748-7

- [3]Charting by exception on a clinical pathway.Research articleShort MS (1997)

## 임상 시나리오

Charting by Exception on a Psychiatric WardDocument only what deviates from the unit's written norms
In charting by exception, the nurse writes narrative notes only for findings that fall outside the ward's defined norms. Normal findings are assumed to meet the standard and are marked on the flow sheet, not written out in longhand.

For a client with schizophrenia, unit norms may include no aggressive behavior, no auditory hallucinations reported, sleeps at least 6 hours, and attends at least one group activity per shift. Only deviations—such as new command hallucinations or agitation—trigger a SOAPIE narrative note.

CautionCBE is valid only when the defined norms are written, unit-specific, and known to every nurse. If a norm is unclear, the nurse must clarify it before relying on the exception-based record.

## 핵심 개념

- **Charting by Exception (CBE)** — A documentation system that records only significant findings or deviations from pre-established written norms, assuming all unrecorded findings are within normal limits.
- **SOAPIE** — An acronym for Subjective, Objective, Assessment, Plan, Intervention, Evaluation; a format for problem-oriented narrative notes.
- **Flow Sheet** — A documentation tool with checkboxes or short entries for routine assessments, allowing normal findings to be recorded efficiently.
- **Defined Norms** — Written, unit-specific standards of expected assessment findings that must be known to all nurses for CBE to be valid.
- **Narrative Note** — A written description of an abnormal finding, intervention, and response, used in CBE only when a client deviates from norms.

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