Who decides the use of charting by exception?

Charting by exception is an employer-driven decision. Organizations choose documentation methods based on their practice setting, client needs, and available systems (like electronic medical records). If your workplace uses charting by exception, it should be supported by clear policies that define what “normal” means and when exceptions must be documented.

What is charting by exception?

Charting by exception is a method where you only document findings or care that falls outside the expected norms. For example, if a client’s condition is stable and unchanged, you may not need to repeat the same documentation each shift. This approach can save time and reduce redundancy—but it must be used correctly and responsibly.