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.

To promote clear communication, for instance, about the location of a patient's abdominal pain or a suspicious mass, anatomists and clinicians typically use imaginary lines to categorize the abdominopelvic cavity into either four quadrants or nine regions to identify organs in the cavity.
The simpler quadrants approach, which is more commonly used in medicine, subdivides the cavity with one horizontal and one vertical line that intersects at the patient's umbilicus (navel). The four quadrants...

Physical assessment of the respiratory tract is critical in identifying potential health issues. One key component of this assessment is palpation, a technique healthcare providers use to assess the body for abnormalities. This content explores the method of palpation in evaluating the respiratory tract, focusing on thoracic palpation and tactile fremitus.
Thoracic Palpation
Thoracic palpation detects tenderness, masses, lesions, respiratory excursions, and vocal fremitus. The nurse assesses...

Effective communication among healthcare professionals during hand-off reporting is essential to delivering safe and continuous patient care. Common professional interactions include reports to healthcare team members, hand-off, and transfer reports. Nurses routinely report information to other healthcare team members and also urgently contact healthcare providers to report changes in patient status.
Standardized methods of communication have been developed to ensure that information is...

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...

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: