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?

a) Charting by exception

b) DAR (data, action of nursing intervention, and response of the patient) report

c) PIE (problem, intervention, and evaluation) report

d) Narrative report

Answer 1

The documentation system used by the nurse, which records only the abnormal findings, is known as charting by exception.

Step-by-step explanation:

The documentation and informatics system being described is known as charting by exception. This method involves noting only those findings that deviate from predefined norms or standards. In the given case, the nurse records only the abnormal findings—a casted left lower extremity due to a heel fracture and pain in the left foot—while all other physical exam and review of system findings are within normal limits, and therefore not explicitly documented. This approach streamlines the documentation process and highlights only the information that requires attention.