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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 III: PIE

Methods of Documentation III: PIE

Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:

Data Collection III

Data Collection III

The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.
The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the patient.

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.

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...

Critical Thinking II

Critical Thinking II

Critical thinking is a cognitive process with several attributes. The attributes of critical thinking include the following:

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Related Experiment Video

Updated: Jun 28, 2026

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Published on: January 16, 2019

Objective structured clinical exams: a critical review.

John L Turner¹, Mary E Dankoski

¹Department of Family Medicine, Indiana University, Indianapolis, IN 46202, USA. jlturner@clarian.org

Family Medicine

|November 7, 2008

Summary

This summary is machine-generated.

Objective Structured Clinical Examinations (OSCEs) are widely used but lack clear superiority over traditional methods. Careful attention to OSCE design and implementation is crucial for valid, reliable, high-stakes assessments.

Related Experiment Videos

Last Updated: Jun 28, 2026

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Published on: January 16, 2019

Area of Science:

Medical Education
Assessment Methods
Clinical Skills Evaluation

Background:

Objective Structured Clinical Examinations (OSCEs) have been utilized since the 1970s.
OSCEs are now integral to the US Medical Licensing Examination for graduates.
Debate persists regarding the superiority of OSCEs compared to traditional assessment methods.

Purpose of the Study:

To review the existing research on the reliability and validity of OSCE testing.
To explore the pros and cons of the OSCE method in medical education.
To identify key considerations for medical educators implementing OSCEs.

Main Methods:

Systematic review of reliability and validity research on OSCEs.
Analysis of factors influencing the validity and reliability of OSCEs.
Discussion of benefits and challenges associated with OSCE implementation.

Main Results:

Research on OSCE reliability and validity does not conclusively demonstrate superiority over traditional methods.
Effective use of OSCEs for high-stakes decisions requires careful attention to content, design, and implementation.
OSCEs offer both recognized and unrecognized advantages for students, faculty, and institutions.

Conclusions:

The effectiveness of OSCEs is contingent upon meticulous test design and execution.
Medical educators must carefully weigh the benefits and drawbacks before adopting OSCEs.
Further research may be needed to fully elucidate the value and optimal application of OSCEs in medical training.