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Related Concept Videos

Data Collection II01:29

Data Collection II

The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and family,...
Data Collection I01:30

Data Collection I

Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, subjective data is collected from the patient, their caregivers, or family members, and objective data is collected through observations and physical assessment. Patients are the primary source of subjective data. Thus information gathered from patients through interviews, observations, and physical examination is primary data. Secondary sources of data...
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.
Nursing Assessment01:29

Nursing Assessment

The two sources for collecting information are primary and secondary. After gathering information, interpretation and validation help to complete the data. The purpose of assessment is to establish data with the initial information, to interpret data about the patient's perceived needs and health problems, and to respond to these problems identified.
The nurse collects all aspects of the patient's health in the initial assessment, establishing priorities for ongoing focused assessments and...
Assessment of the Cardiovascular System I: Subjective Data01:23

Assessment of the Cardiovascular System I: Subjective Data

A thorough health history and physical assessment are essential for identifying cardiovascular disease (CVD) symptoms and distinguishing them from other health issues.
Initial Enquiry
Ask the patient about their primary concern and thoroughly explore all reported symptoms.
Medical History
Investigate past illnesses affecting the cardiovascular system, such as angina, anemia, rheumatic fever, congenital heart disease, stroke, thrombophlebitis, dysrhythmias, varicosities
Inquire about symptoms...
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: May 27, 2026

Using Practice Testing, Public Speaking, and Source Monitoring to Examine the Influences of Learning Strategies and Stress on Episodic Memory
07:59

Using Practice Testing, Public Speaking, and Source Monitoring to Examine the Influences of Learning Strategies and Stress on Episodic Memory

Published on: June 14, 2019

Evidence-based history taking under "time constraint".

Alireza Moayyeri1, Akbar Soltani, Hamideh Moosapour

  • 1Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom.

Journal of Research in Medical Sciences : the Official Journal of Isfahan University of Medical Sciences
|November 18, 2011
PubMed
Summary

Experienced physicians use "key pointers" and evidence-based medicine (EBM) to improve diagnostic efficiency. This approach reduces diagnostic time and errors, aiding clinicians facing time constraints in patient care.

Keywords:
Clinical CompetenceDiagnosisEvidence-Based MedicineHospitalOutpatient ClinicsTime Management

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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

Related Experiment Videos

Last Updated: May 27, 2026

Using Practice Testing, Public Speaking, and Source Monitoring to Examine the Influences of Learning Strategies and Stress on Episodic Memory
07:59

Using Practice Testing, Public Speaking, and Source Monitoring to Examine the Influences of Learning Strategies and Stress on Episodic Memory

Published on: June 14, 2019

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

Area of Science:

  • Clinical Medicine
  • Medical Education

Background:

  • Physicians worldwide face significant time constraints during patient consultations.
  • Diagnostic skills are particularly challenged under time pressure, leading to potential errors.

Purpose of the Study:

  • To evaluate the diagnostic strategies employed by experienced physicians.
  • To assess the potential contribution of evidence-based medicine (EBM) to these strategies.

Main Methods:

  • Review of diagnostic approaches used by veteran internists in busy outpatient settings.
  • Development of an evidence-based diagnostic model integrating clinical experience and research evidence.

Main Results:

  • Clinicians utilize specific "key pointer" questions for efficient decision-making.
  • Incorporating evidence-based resources and "key pointers" with high likelihood ratios can reduce diagnostic time and errors.

Conclusions:

  • An evidence-based diagnostic model, combining clinical expertise with research evidence, can help physicians overcome time constraints.
  • Clinical trainees can benefit by developing their own sets of evidence-based "key pointers".