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?

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.

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