Question

The nurse is given a form with preset standard findings for recording a progress note. The nurse reports the findings in the following way: 'Physical Exam: All systems within normal except left lower extremity, casted d/t to heel fracture. Review of Systems: All normal except pain in the left foot.' What kind of documentation and informatics is this?

Answer 1

Answer:

Charting by exception (CBE)

Explanation:

Based on the information provided within the question it can be said that the type of documentation and information being used is known as Charting by exception (CBE). This is a method of documenting that is based on pre-defined standards, practice, as well as predetermined criteria for assessments and interventions while all of the extra findings are written down with complete detail.

Answer 2

Answer: the documentation is CHARTING by EXCEPTION

Explanation:

Charting by exception makes use of forms that usually have predefined normal findings. The nurse simply documents findings that tend to go out of the norm or standardization. Every other findings are presumed to be normal except it is documented. The PIE (Problem-Intervention-Evaluation) basically documents problem-intervention-evaluation and it isn't narrative.

A narrative report is all about information documented in a story-like style.

The DAR (Data, Action of Nursing Intervention, Response of the client) report elaborately describes the concerns of the client, his/her condition, behaviour, symptoms, changes in the patients condition etc.