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?
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The nurse is given a form with preset standard findings for recording a progress note. The nurse rep...
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