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Methods of Documentation II: POMR

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.

Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation

Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation

Evaluation of the teaching process enables the nurse to determine if the patient's learning needs were met and if training was effective. If the expected outcomes are not met, the care plan is revised, and additional education or reinforcement is provided. Nurses can ask questions after the session or obtain feedback to assess the patient's understanding of the topic.
Nurses can use several methods to evaluate patient outcomes. For example, oral questions can assess cognitive learning, patient...

Methods of Documentation V: CBE

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...

Methods of Documentation VI: Case Management Model

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic illness...

Nursing Process for Patient and Caregiver Teaching II: Planning and Implementation

Nursing Process for Patient and Caregiver Teaching II: Planning and Implementation

Planning for learning involves the development of a teaching plan. Teaching plans are similar to nursing care plans—both follow the steps of the nursing process. Planning in the teaching process involves setting goals and outcomes. Here, goals identify what a patient needs to achieve to understand a healthcare topic better, whereas the outcomes are the action to be performed by the patient to achieve the goal within a timeframe. For example, if the goal is to educate the patient about insulin...

Methods of Documentation VII: EMR

Methods of Documentation VII: EMR

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...

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Related Experiment Video

Updated: Jun 29, 2026

Bridging the Technology Divide in the COVID-19 Era: Using Virtual Outreach to Expose Middle and High School Students to Imaging Technology

Bridging the Technology Divide in the COVID-19 Era: Using Virtual Outreach to Expose Middle and High School Students to Imaging Technology

Published on: September 28, 2022

Organizing an effective continuous medical education session.

¹Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.

The Journal of the Association of Physicians of India

|October 14, 2008

Summary

Effective continuing medical education (CME) requires understanding adult learning principles and physician needs. Interactive sessions and pre/post-tests are key to improving physician knowledge and practice.

Area of Science:

Medical Education
Physician Professional Development

Background:

Continuing Medical Education (CME) is crucial for lifelong learning and evidence-based medical practice.
Physicians rely on CME programs to stay updated with current medical information.
Effective CME requires understanding adult education principles and physician needs.

Purpose of the Study:

To emphasize the importance of needs assessment in CME curriculum development.
To highlight the characteristics of effective CME activities for improving physician competence.
To advocate for robust evaluation methods beyond participant satisfaction.

Main Methods:

Conducting physician needs assessments prior to curriculum design.
Organizing interactive CME sessions utilizing multiple instructional methods for small, single-discipline groups.

Related Experiment Videos

Last Updated: Jun 29, 2026

Bridging the Technology Divide in the COVID-19 Era: Using Virtual Outreach to Expose Middle and High School Students to Imaging Technology

Bridging the Technology Divide in the COVID-19 Era: Using Virtual Outreach to Expose Middle and High School Students to Imaging Technology

Published on: September 28, 2022

Implementing pre and post-tests with multiple-choice questions to assess knowledge and skill improvement.

Main Results:

Interactive, small-group sessions are more effective in changing physician knowledge and behavior.
Needs assessments guide the development of relevant and impactful CME curricula.
Pre and post-tests, when appropriately constructed, effectively measure improvements in physician knowledge and application.

Conclusions:

CME organizers must prioritize needs assessment and adult learning principles.
Interactive and multi-modal teaching strategies enhance CME effectiveness.
Evaluating CME impact requires assessing changes in physician knowledge, skills, and attitudes, not just satisfaction.