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Related Concept Videos

Nursing Diagnosis01:22

Nursing Diagnosis

Following assessment, a nursing diagnosis is the next step in the nursing process. It begins after the nurse has collected and recorded the patient data. The purpose of diagnosing is to identify how the client responds to actual or potential health processes, identify factors that bestow or that cause health problems, the etiologies, and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.
The nursing diagnosis focuses on evidence-based...
Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
SBAR II: Application of SBAR01:14

SBAR II: Application of SBAR

SBAR is an effective communication tool used by healthcare professionals to communicate patient information accurately. SBAR stands for Situation, Background, Assessment, and Recommendation. For a better understanding, an example is given below.
SBAR Report from a Nurse to a Health Care Provider
S: "Hello, Dr. Smith. This is Jane, RN, from the Med Surg unit. I am calling to tell you about Ms. White in Room 210, who is experiencing increased pain and redness at her incision site. Her recent...
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.
Formulating and Validating Nursing Diagnosis I01:26

Formulating and Validating Nursing Diagnosis I

A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing interventions. The standardized terminologies of a nursing diagnosis help nurses identify and treat patients' problems. Every electronic health record that uses nursing diagnosis must employ standard diagnostic terminology. Developing an efficient, individualized care plan begins with accurate nursing diagnoses.
There are thirteen domains for...
Formulating and Validating Nursing Diagnosis II01:25

Formulating and Validating Nursing Diagnosis II

Nursing diagnoses represent a problem validated by major defining characteristics. There are four categories of nursing diagnoses: problem-focused, risk, health promotion or wellness, and syndrome. The anatomy of a nursing diagnosis includes three components: problem statement or diagnostic label, defining characteristics, and related factors.
Risk nursing diagnoses represent clinical judgments of an individual, family, or community more vulnerable to developing the health problem than others...

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Related Experiment Video

Updated: May 30, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
07:50

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

Beyond the chief complaint.

Norman A Clemens1

  • 1Case Western Reserve University and Cleveland Psychoanalytic Center.

Journal of Psychiatric Practice
|July 22, 2011
PubMed
Summary
This summary is machine-generated.

Understanding patient life events and emotions is crucial for psychiatric evaluations. This approach builds trust and informs effective psychotherapy for conditions like psychosis, panic disorder, and depression.

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Area of Science:

  • Psychiatry
  • Clinical Psychology
  • Mental Health

Background:

  • Psychiatric evaluations require understanding patient history.
  • Life events and emotional states are key to symptom emergence.
  • Therapeutic alliance is foundational for psychotherapy.

Purpose of the Study:

  • To highlight the importance of narrative in psychiatric assessments.
  • To demonstrate how life events inform diagnosis and treatment.
  • To illustrate common discovery patterns in common psychiatric disorders.

Main Methods:

  • Analysis of three composite case examples.
  • Focus on the emergence of presenting symptoms.
  • Exploration of life events and emotional states.

Main Results:

  • Narrative exploration is vital for psychiatric evaluations.
  • Understanding patient history builds therapeutic alliance.
  • This method aids in developing effective psychotherapeutic plans.

Conclusions:

  • Psychiatric evaluations benefit from in-depth patient narratives.
  • Therapeutic alliance is strengthened by exploring life events.
  • Effective treatment planning for psychotic illness, panic disorder, and depression relies on this approach.