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Methods of Documentation II: POMR01:26

Methods of Documentation II: POMR

The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
Imaging Studies I: CT and MRI01:14

Imaging Studies I: CT and MRI

Introduction: MRI and CT scans are crucial advancements in medical imaging techniques, playing a vital role in diagnosing conditions related to the gastrointestinal (GI) system. Each scan serves distinct purposes, targets specific areas, and requires unique nursing duties.
Description of the Procedures
Computed Tomography (CT) scan:
Computed Tomography (CT) scans use X-ray technology to generate detailed images of bones, organs, and tissues. During the scan, the patient lies on a moving table...
Radiological Investigation I: X-ray and CT01:30

Radiological Investigation I: X-ray and CT

Radiological investigations, including X-rays and computed tomography (CT) scans, are critical for diagnosing and evaluating various medical conditions. These imaging techniques provide valuable insights into the body's internal structures, aiding in the detection of abnormalities, assessment of disease progression, and development of treatment strategies. This article delves into two primary radiological investigations, chest X-rays and CT scans, outlining their purpose, procedures, and the...
Radiological Investigation III: Pulmonary Angiogram and PET Scan01:13

Radiological Investigation III: Pulmonary Angiogram and PET Scan

Radiological investigations are paramount in the diagnosis and management of various pulmonary diseases. Two essential investigations are the Pulmonary Angiogram and the Positron Emission Tomography (PET) Scan.
Pulmonary Angiogram
A Pulmonary Angiogram is an invasive procedure involving injecting a contrast medium through a catheter threaded into the pulmonary artery or the right side of the heart to visualize the pulmonary vasculature. Computed Tomography (CT) scans have mainly replaced this...
Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...

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Related Experiment Video

Updated: Jul 14, 2026

Clinical Imaging of Microwave Mammography
05:28

Clinical Imaging of Microwave Mammography

Published on: November 14, 2025

Documentation for mammographers.

Monica M Hendricks

    Radiologic Technology
    |May 24, 2007
    PubMed
    Summary

    Effective mammographer documentation ensures continuity of patient care. Accurate recording of patient history and quality control tests is crucial for breast imaging procedures.

    Area of Science:

    • Radiologic Technology
    • Medical Imaging
    • Breast Health

    Background:

    • Mammographers play a critical role in breast imaging.
    • Accurate patient information transfer to radiologists is essential.
    • Documentation quality directly impacts patient care continuity.

    Purpose of the Study:

    • To provide mammographers with tools for effective documentation.
    • To emphasize the importance of precise patient history recording.
    • To highlight the role of documentation in quality control.

    Main Methods:

    • Review of best practices in medical record keeping.
    • Guidelines for documenting clinical concerns and patient history.
    • Procedures for recording quality control tests and actions.

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    Dendra2 Photoswitching through the Mammary Imaging Window

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    Detection of Architectural Distortion in Prior Mammograms via Analysis of Oriented Patterns
    13:44

    Detection of Architectural Distortion in Prior Mammograms via Analysis of Oriented Patterns

    Published on: August 30, 2013

    Related Experiment Videos

    Last Updated: Jul 14, 2026

    Clinical Imaging of Microwave Mammography
    05:28

    Clinical Imaging of Microwave Mammography

    Published on: November 14, 2025

    Dendra2 Photoswitching through the Mammary Imaging Window
    09:12

    Dendra2 Photoswitching through the Mammary Imaging Window

    Published on: June 5, 2009

    Detection of Architectural Distortion in Prior Mammograms via Analysis of Oriented Patterns
    13:44

    Detection of Architectural Distortion in Prior Mammograms via Analysis of Oriented Patterns

    Published on: August 30, 2013

    Main Results:

    • Mammographers equipped with tools for consistent documentation.
    • Improved accuracy in relaying patient information.
    • Standardized recording of quality control measures.

    Conclusions:

    • Effective documentation by mammographers is vital for patient care.
    • Consistent record-keeping enhances communication between mammographers and radiologists.
    • Adherence to documentation standards ensures quality in breast imaging.