The answer is Charting by exception (CBE).
Charting by exception is a documentation method where only deviations from the norm or unexpected findings are recorded. This approach assumes that all standards of care are met unless otherwise documented. It is efficient and reduces the amount of documentation required, focusing only on significant changes in the patient's condition.
SOAP documentation stands for Subjective, Objective, Assessment, and Plan. It is a structured method of documentation that includes all aspects of patient care, not just unexpected findings. It is comprehensive and used to ensure all relevant information is captured systematically.
The Problem-oriented medical record is a method of documentation that organizes information around the patient's specific problems. It includes a database, problem list, plan, and progress notes. It is not limited to unexpected findings but rather focuses on all aspects of the patient's problems and care.
Focus charting uses the DAR format, which stands for Data, Action, and Response. It is a method that centers on specific patient concerns or behaviors, not just unexpected findings. It provides a comprehensive view of the patient's condition and the care provided.