Every clinical reference 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 day auditable.
Mode A — normal findings with skill justification
Use when the system is unremarkable this shift. The Mode A paragraph documents the findings and articulates the reason a licensed clinician was still required and why today. Both elements are mandatory; either alone fails. Output: one full paragraph, or a short-form variant for quick charting. Use when a system is not the focus of the shift but must be assessed because of a diagnosis-related risk, medication effect, or surveillance requirement.
Mode B — focused assessment (abnormal or at-risk)
Use when findings are abnormal, the system is the focus of the shift, or a known risk requires structured detail. Mode B unfolds into Subjective, Objective, and Measure prompts, then interventions, response, teaching, and coordination. Use for a change of condition, new symptoms, or the assessment window feeding an MDS.
