Every body-system module is structured around two documentation modes. Choosing between them is a thirty-second decision that determines which template to use; using them correctly is what makes the visit auditable.
Mode A — normal findings with skill justification
Use when the system is unremarkable. The Mode A paragraph documents the WNL findings and articulates the reason an RN was still required. Both elements are mandatory; either alone fails.
When to use: a system is not the focus of today’s visit but must be assessed because of diagnosis-related risk, medication effects, or surveillance requirements.
Output: one full paragraph, or a short-form variant for quick charting.
Mode B — focused assessment (abnormal or at-risk)
Use when findings are abnormal, the system is the focus of the visit, or a known risk requires structured detail. Mode B unfolds into Subjective, Objective, and Measure prompts.
When to use: primary visit focus; abnormal findings; recent change in condition; first start-of-care or recertification assessment; new symptoms reported.
Output: structured prompts followed by interventions, response, teaching, and care coordination.
