If you have been a nurse for even one shift, you know this truth: charting takes forever. You finish giving medications, answering call lights, and comforting a worried family. Then you sit down to type or write everything that happened. Sometimes, charting takes longer than the patient care itself. That is why many hospitals use a system called “Charting by Exception” (CBE). This system tries to save time. It asks nurses to only write down things that are not normal. If something is normal, you do not write much about it. You just check a box or leave it blank.

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But is CBE safe? Is it legal? And how do you actually do it the right way? In this blog, we will explain everything. We will show you how to chart by exception, give examples, compare it to focus charting, and talk about the risks. By the end, you will know if CBE is right for your unit and how to protect your nursing license while using it.

What Is Charting by Exception?

Charting by Exception (often called CBE) is a way of documenting patient care where you only write down things that are not normal. The word “exception” means something that is outside the usual or expected range. If a patient’s vital signs, skin color, lung sounds, or behavior match what the hospital says is “normal,” you do not write long sentences about them. You simply check a box, write “WNL” (within normal limits), or leave that section blank.

Think of it like this. Imagine a teacher who only writes notes home when a student misbehaves. If the student sits quietly, does their work, and raises their hand, the teacher writes nothing. But if the student talks out of turn or runs in the hall, the teacher writes a note. CBE works the same way. Normal equals no note. Abnormal equals a short, clear note describing what you saw and what you did.

CBE is not about being lazy or skipping work. It is about saving time so you can spend more minutes at the bedside. Hospitals created CBE because traditional charting required nurses to write long paragraphs for every body system every single shift. That took hours. CBE cuts the wasted time while still creating a legal record. But you must understand the rules first. If you use CBE the wrong way, you can miss important changes or hurt your patient. The next sections will teach you the right way.

Charting by Exception Documentation

Documentation is the legal record of everything you did or did not do. With Charting by Exception, your documentation looks different from old-style charting. Old charting had long sentences for every body part. CBE documentation has mostly checkboxes, short phrases, and occasional narrative notes.

So what exactly goes into CBE documentation?

The flow sheet is your main document.

In CBE, the flow sheet is king. This is a one-page form with rows for body systems (cardiac, respiratory, skin, etc.) and columns for time. At each assessment time, you put a checkmark or “WNL” in the box if the finding is normal. If the finding is abnormal, you write the abnormal value in the box. Then you write a separate note explaining that abnormal finding.

For example:

• Respiratory box: “WNL” means lungs clear, breathing easy.
• Cardiac box: “HR 110” (written small in the box). Then in the notes section: “HR 110. Patient in bed watching TV. No chest pain. Dr. Smith aware.”

You also document any nursing care you gave.

Even if the patient is normal, you still document tasks. For example:

• Medications given (name, dose, time, route)
• Wound care performed
• Patient education provided
• Family notified of updates

These tasks are not “exceptions.” They are required. So do not skip them. CBE does not mean you stop charting tasks. It means you stop charting long descriptions of normal findings.

Your admission assessment is longer.

The first time you see a patient, you cannot use CBE shortcuts. You must do a complete, detailed admission assessment. Write down every finding, normal and abnormal. Why? Because you need to establish what is normal for this patient. Maybe their blood pressure is normally 90/60. That is low for most people, but normal for them. If you only chart exceptions starting at admission, you might miss that baseline.

After the admission assessment, you switch to CBE for the rest of the stay.

Do not forget to chart your reassessments.

If a patient has an exception (like a fever of 101.5), you must reassess. Each time you reassess, document the new finding. Write a short note: “1300: Temperature 100.2. Given Tylenol at 1230. Patient drinking water.” Then next reassessment: “1400: Temperature 99.1. Continues to improve.”

If you stop documenting the exception, a reader will think you stopped paying attention. Always close the loop. Show when the exception returns to normal.

A real documentation mistake I have seen:

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A new nurse had a patient with low oxygen saturation (88%). She gave oxygen and wrote one note: “O2 given.” Then she never wrote another note. The patient’s oxygen improved to 94% two hours later, but she did not document that. The next nurse came on shift, saw only the low number, and thought the patient was still critical. That caused a delay in care.

Always document the resolution of an exception. Write: “O2 sat now 94% on 2L nasal cannula. No distress.”

Good CBE documentation tells a story: here is the normal, here is the exception, here is what I did, here is the new normal. If any part of that story is missing, your documentation is incomplete.

How to Chart by Exception

Charting by Exception is simple in theory. You create a list of normal findings for a patient. These normal findings are called “standards” or “norms.” Then, you only document when a finding is outside that normal list. If everything matches the normal list, you do not write long notes. You might write one phrase like “All systems within normal limits” or check a box.

Here is how to do it step by step.

Know your hospital’s normal flow sheet.

Every hospital that uses CBE has a standard form. This form lists normal vital signs, normal skin condition, normal lung sounds, normal behavior, and so on. Before your shift starts, read that form. Know what counts as “normal” for an adult patient, for a child, or for an older adult. If you do not know the normal, you cannot spot the exception.

Assess the patient completely.

You still do a full head-to-toe assessment. That never changes. But as you assess, you compare each finding to the hospital’s normal list. For example, you listen to the lungs. They are clear. The normal list says “clear lungs bilaterally” is normal. So you do not write a sentence about lungs. You simply leave that section blank or check a box that says “WNL” (within normal limits).

Only write when something is abnormal.

Now you find something not normal. Maybe the patient’s heart rate is 110, but normal is 60 to 100. Or the patient’s skin is yellow, but normal is pink and warm. That is an exception. You must write a short note about that exception. You describe exactly what you saw, where it was, and what you did about it. For example: “Heart rate 110 at rest. Patient denies chest pain. Notified Dr. Jones. Will continue to monitor.”

Follow your hospital’s rules for reassessment.

CBE also has rules about how often you must check the patient. Most hospitals say you must do a full assessment every 8 hours. But for exceptions, you might reassess every 1 to 2 hours. If an exception is getting worse, you write a new note each time. You never assume the exception will fix itself.

Use the correct abbreviations.

Common CBE abbreviations include:

• WNL = Within Normal Limits
• NAD = No Acute Distress
• DAT = Diet as Tolerated
• A&O x3 = Alert and Oriented to Person, Place, and Time

But be careful. Some hospitals do not allow certain abbreviations. Always check your facility’s approved list. If you use a wrong abbreviation, a lawyer may say your charting is unclear.

An example of a CBE shift note:

“0800: Patient awake, alert. All vital signs WNL. Lungs clear. Abdomen soft. Skin warm and dry. No new exceptions noted. Patient resting comfortably.”

That short note covers many body systems. In traditional charting, that could be two paragraphs. In CBE, it is one sentence. That is the time-saving power.

But remember: if you skip the real assessment and just write “WNL,” that is dangerous. You must actually check the patient first. Charting by exception does not mean thinking by exception. You still think like a full nurse.

Nursing Charting by Exception (CBE) Examples

Examples help more than theory. Let me give you five real-world examples of how to use CBE on different types of patients. Each example shows the normal finding, the exception, and the correct note.

Post-surgery patient

Normal finding: Incision is dry, clean, edges together, no redness.
Exception: You see redness and a small amount of yellow drainage.
Your CBE note: “0900: Abdominal incision. 3cm area of redness at lower edge. Small amount yellow-green drainage noted. No foul odor. Cleaned with normal saline. Applied dry sterile dressing. Notified surgical resident Dr. Lee. Will reassess in 2 hours.”

Elderly patient with confusion

Normal finding: Alert and oriented to person, place, and time.
Exception: Patient does not know what year it is or where they are.
Your CBE note: “1400: Patient awake but disoriented to time and place. Knows own name. Unable to state current year. No previous confusion per family. Blood pressure 110/70, glucose 98. Notified primary care provider. Family at bedside. Will continue to reorient.”

New mother after birth

Normal finding: Uterus feels firm, bleeding is light like a period.
Exception: Uterus feels soft (boggy) and bleeding is heavy with large clots.
Your CBE note: “0300: Uterus boggy at umbilicus. Heavy bleeding with clots size of golf balls. Massaged uterus. Fundus became firm. Bleeding decreased to moderate. Vital signs stable. Provider notified. Will reassess in 15 minutes.”

Child with asthma

Normal finding: Breathing easy, no wheezing, oxygen saturation 95% or more.
Exception: Child is wheezing, using chest muscles to breathe, oxygen saturation 90%.
Your CBE note: “1000: Child sitting upright, nasal flaring. Wheezing heard in all fields. O2 sat 90% on room air. Albuterol nebulizer given. O2 sat 93% after treatment. Wheezing less. Notified pediatrician. Parent teaching done on inhaler use.”

Patient refusing medication

Normal finding: Patient takes all medications as ordered.
Exception: Patient refuses blood pressure pill because they feel dizzy.
Your CBE note: “0800: Patient refused lisinopril 10mg. States ‘I feel dizzy when I stand up.’ Blood pressure sitting 100/60, standing 85/50. Held medication. Notified provider. New order received to hold for blood pressure below 110/70. Patient verbalized understanding.”

Notice a pattern in all these examples? Every note has four parts:

1. What I found (the exception)
2. What I did
3. Who I told
4. What I will do next

That is the safe CBE formula. Use it every time you write an exception note.

Focus Charting vs Charting by Exception

New nurses often confuse Focus Charting with Charting by Exception. They sound similar, but they are not the same. You need to know the difference because your hospital may use one, the other, or both in different units.

What is Focus Charting?

Focus Charting organizes notes around a patient’s problem or strength. Each note has three parts: Data, Action, Response (DAR). You write a note for each “focus.” A focus can be a diagnosis (like “pain”), a symptom (like “nausea”), or even a positive event (like “patient walked to bathroom”).

Example of Focus Charting note:

• Focus: Pain
• Data: Patient rates pain 7/10 in right knee. Facial grimacing.
• Action: Gave morphine 2mg IV per order. Applied ice pack.
• Response: 30 minutes later, patient rates pain 3/10. Smiling. Resting in bed.

What is Charting by Exception?

CBE, as you learned, only documents abnormal findings. It uses flow sheets and short notes. It does not require a DAR format. CBE assumes normal unless you write otherwise.

Key differences in a simple table:

Feature	Focus Charting	Charting by Exception
Main format	DAR (Data, Action, Response)	Flow sheet + brief exception notes
Documents normal findings?	Yes, if relevant to the focus	No, normal is assumed
Time to complete	Moderate to long	Short
Best for	Complex patients with many problems	Stable, predictable patients
Legal risk	Lower (more details)	Higher if done poorly

When to use which?

Use Focus Charting for:

• Intensive care unit (ICU) patients
• Patients with rapid changes
• Mental health patients (behavior focuses)
• Rehabilitation patients (goal focuses)

Use Charting by Exception for:

• Medical-surgical floor stable patients
• Long-term care residents with no acute changes
• Post-op day 2 or 3 patients doing well
• Same-day surgery patients

Can you use both?

Yes. Many hospitals use a hybrid system. They use CBE for the routine vital signs and daily assessments. Then they use Focus Charting for specific problems like wound care, pain management, or patient teaching. The key is to be consistent. Do not jump between styles randomly. Pick one system per note and stick to it.

I once worked on a telemetry unit where we used CBE for the flow sheet and Focus Charting for any change in heart rhythm. That hybrid worked well. It saved time on normal charting but gave us space to describe complex cardiac events.

My advice: Ask your educator which system your hospital prefers. If they say “both,” ask for a written example. Then keep that example at your workstation until you memorize it.

Legal Risks of Charting by Exception

Now let us talk about something most nurses do not like to discuss: legal risks. Charting by Exception can save you time, but it can also hurt you in court if you use it carelessly. I have seen nurses lose lawsuits not because they gave bad care, but because their CBE charting was incomplete.

Assuming normal without checking.

The biggest legal danger is “charting by habit.” You check the WNL box without actually assessing the patient. A lawyer will ask you: “Nurse, you wrote WNL for lung sounds. But the patient stopped breathing at 2 AM. How do you know lungs were normal at 1 AM if you did not listen?” If you cannot say “I listened with my stethoscope,” you lose.

Protection: Always assess before you chart. Never check a box based on how the patient looked from the doorway. Touch the patient. Listen. Look. Then document.

Missing a change because you did not write it down.

CBE only documents exceptions. But what if an exception becomes normal? You might stop writing about it. Then if that problem comes back, there is no record. A lawyer will argue that you failed to monitor because you did not chart.

Example: A patient had a fever. You charted it. The fever went away. You stopped charting temperature because it was now “normal.” Two days later, the fever returns to 103. You chart it. But there is no record that the patient was fever-free for 48 hours. The doctor thinks the fever is new. Treatment is delayed.

Protection: Even when an exception resolves, write one closing note. Example: “Fever resolved. Temperature 98.6 for last 24 hours. No antibiotics given. Will continue daily monitoring.”

Using unclear abbreviations.

CBE uses many abbreviations. But if an abbreviation is not on your hospital’s approved list, a judge may call it “illegible.” If a lawyer cannot read your charting, they will assume you made a mistake.

Real case: A nurse wrote “SOB” for shortness of breath. That is common. But she also wrote “SOB” for “short of breath” in one note and “seen on bedside” in another note. In court, no one could tell which she meant. The jury decided against her.

Protection: Use only the abbreviations on your unit’s list. If you are unsure, write the full words. It takes five extra seconds and can save your license.

Failing to notify a provider.

In CBE, you document exceptions. But documenting is not enough. You must also tell the doctor or nurse practitioner. If you chart “BP 180/100” and do not call anyone, the lawyer will ask: “Why did you document a dangerous number but take no action?”

Protection: After you find an exception, ask yourself: “Does this need a provider notification?” If yes, call. Then document in your note: “Notified Dr. Smith at 0900. New order received for labetalol 10mg IV.”

Copying forward without updating.

Electronic medical records (EMRs) let you copy your last note. Many nurses copy a note that says “All systems WNL” from yesterday. But today, the patient has a new rash. Because you copied, you did not chart the rash. The rash gets worse. Now you have no documentation of when it started.

Protection: Never copy a note without reassessing. Treat every copy as a new assessment. Delete the old WNL statements and write new ones only after you check.

The bottom line on legal risk: CBE is not dangerous if you are honest. But it punishes laziness. If you assess, document honestly, notify providers, and close the loop, CBE is perfectly safe and legal. If you cut corners, CBE will expose every corner you cut.

Disadvantages of Charting by Exception

I have used CBE for a long time. I like it for stable patients. But I will be honest: CBE has real disadvantages. You need to know these so you can decide when to use it and when to avoid it.

New nurses struggle with it.

New nurses do not yet know what “normal” looks like. They have not seen 100 healthy lungs or 50 normal incisions. When you tell a new nurse “only chart exceptions,” they may miss subtle abnormal findings because they do not realize it is abnormal. They think it is normal. So they chart nothing. The patient gets worse.

Solution: New nurses should not use CBE for the first three months. They should do full narrative charting. After three months, they can slowly add CBE with a preceptor watching.

It hides gradual changes.

Some problems get worse slowly. A patient’s breathing becomes slightly more difficult over 12 hours. Each hour, the change is small. No single hour is an “exception” if your hospital defines exception as a big change. But by hour 12, the patient is in respiratory failure. CBE never caught it because each small step was not an exception.

Solution: Add a “trend note” every 4 hours. Write: “Breathing slightly more labored than 4 hours ago. Lung sounds remain clear. Will continue to monitor.” That documents the trend without waiting for a big exception.

It does not work well for confused or nonverbal patients.

If a patient cannot tell you how they feel, you need more detail. A confused patient may have a normal heart rate and normal blood pressure but be in terrible pain. CBE would miss that because vital signs are normal. You need to chart behavior, facial expressions, and family reports.

Solution: For confused or nonverbal patients, use Focus Charting instead. Or add a behavior section to your CBE flow sheet. Never rely only on vital signs for these patients.

It can lead to lazy thinking.

I have seen nurses become “checkbox nurses.” They go through the flow sheet, check WNL for everything, and never stop to think. They stop asking “Why is this patient here?” or “What could go wrong?” They just check boxes. That is dangerous. Nursing is thinking, not checking.

Solution: Before you finish your CBE charting, ask yourself one question: “What am I worried about?” Write the answer in one sentence. Example: “Worried about fall risk because patient tried to get up twice.” That one sentence forces you to think like a nurse, not a data entry clerk.

Legal discovery looks bad for CBE.

If a patient sues the hospital, their lawyer will get all your charting. A CBE chart has mostly empty boxes and short notes. The lawyer will say to the jury: “Look at this empty chart. The nurse barely wrote anything. How can we trust that she did anything?” Even if you gave excellent care, the empty chart looks like you were lazy.

Solution: Add one or two “free text” comments per shift. Write something human like “Patient smiled today” or “Family thanked staff for care.” These small notes show you were present and engaged. They make the chart look alive, not empty.

My final honest opinion:

CBE is a tool, not a religion. Use it for stable, predictable, communicating patients. For everyone else, add extra detail. Do not let any hospital policy force you to use CBE on a patient who needs full narrative charting. You are the nurse at the bedside. You know what your patient needs. If that means writing a long note, write it. No one will punish you for too much documentation. But they will punish you for too little.

Final Words

Charting by Exception can save you hours each week. Those hours can go back to your patients, your family, or your sleep. But saving time never comes before safety.

Remember the three golden rules of CBE:

1. Assess first, then check the box.
2. Write a note for every exception with four parts: what you found, what you did, who you told, and what comes next.
3. When in doubt, write more, not less.

You became a nurse to help people heal. Charting is not the reason you love nursing. But good charting protects your patients and your license. CBE is one way to chart well without losing your mind. Learn it. Use it wisely. And never let a checkbox replace your nursing judgment. Now go take care of your patients. And chart smart. 

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