While I do love the CBE system generally, if it's done truly as "Chart by Exception" when your patient has absolutely nothing physically wrong with them, you do end up with a basically blank chart, with a note stating something along the lines of "Patient assessed head to toe, no abnormal findings noted." This would be GREAT if your organization trusted you and would back you 100% if your chart was brought into question. An indication that your organization doesn't trust you that much is seeing "normal" in various parts of your assessment charts when you're supposed to be doing CBE. If it's "normal" you wouldn't be visiting that section of the chart and therefore wouldn't have to check the "normal" box.I love the chart by exception method. When I first started EMS, it was long narrative format and if you did not list it, then it did not happen and/or it gave a hole in the story wide enough for any QA Officer or Attorney to drive a truck through.
Now, the mentality is everything is normal unless stated otherwise (this does not mean we do not chart some normals such as LS or Bowel Sounds, etc). So much easier and quicker. And yes, it now places a larger burden of proof on any QA or Attorney to call into question that something was not assessed. Do some providers abuse that system, yes of course, it is gonna happen in any system, any format. You will always have halfarse providers or the proverbial pencil whippers. Guess this is where Veracity and Integrity come into play...and those are usually not behaviors which need to be learned after entering the professional world...hopefully they existed long before.