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Related Concept Videos

Methods of Documentation I: Source-Oriented Records01:18

Methods of Documentation I: Source-Oriented Records

Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
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.
Methods of Documentation VI: Case Management Model01:15

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...
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...
ER Retrieval Pathway01:45

ER Retrieval Pathway

In the secretory pathway, vesicles transport proteins from one cellular compartment to another in forward transport to deliver the protein to its correct location. Occasionally, misfolded proteins and incorrect proteins escape their original compartments, and a retrieval pathway is used to return the escaped proteins to their original compartment.
The ER uses many checkpoints to prevent the entry of incorrectly folded or a resident protein as cargo onto a transport vesicle. These mechanisms...

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Related Experiment Video

Updated: May 22, 2026

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way
04:45

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

Published on: May 10, 2021

O' surgery case log data, where art thou?

Mayur B Patel1, Oscar D Guillamondegui, Mickey M Ott

  • 1Surgical Service, Veterans Affairs (VA) Tennessee Valley Healthcare System, Nashville, TN, USA. mayur.b.patel@Vanderbilt.edu

Journal of the American College of Surgeons
|May 29, 2012
PubMed
Summary
This summary is machine-generated.

This study demonstrates how the American College of Surgeons (ACS) Case Log effectively tracks acute care surgery fellow experiences, meeting American Board of Surgery Maintenance of Certification requirements and enhancing surgical training documentation.

Related Experiment Videos

Last Updated: May 22, 2026

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way
04:45

Intraoperative Assessment of Resection Margins in Oral Cavity Cancer: This is the Way

Published on: May 10, 2021

Area of Science:

  • Surgical Education
  • Medical Informatics
  • Acute Care Surgery

Background:

  • The American College of Surgeons (ACS) Case Log is a data system that meets American Board of Surgery (ABS) Maintenance of Certification (MOC) requirements.
  • The ACS Case Log offers extensive data fields suitable for various surgical subspecialties.
  • A novel method for capturing, categorizing, and reporting acute care surgery fellows' experiences using the ACS Case Log was developed.

Purpose of the Study:

  • To implement and evaluate a data capture and reporting system for acute care surgery fellows using the ACS Case Log.
  • To ensure compliance with ABS MOC program requirements through detailed logging of surgical experiences.
  • To create a flexible and comprehensive system for monitoring fellow performance in acute care surgery.

Main Methods:

  • Acute care surgery fellows were mandated to log clinical experiences in the ACS Case Log starting July 2010.
  • Case logging followed institutional billing documentation rules, incorporating keywords for services and resuscitation types.
  • Data were exported, deidentified, structured by Current Procedural Terminology (CPT) codes relevant to acute care surgery, and stratified by fellow and training year.

Main Results:

  • Fifteen distinct report types were generated, covering operative experience by service, procedure categories, resuscitations, and specialized services (e.g., ultrasound, airway, ICU).
  • Results are accessible nationally via a secure web application and can be exported in multiple formats.
  • The system successfully categorized diverse surgical procedures and clinical activities.

Conclusions:

  • The developed ACS Case Log system effectively meets ABS MOC requirements for acute care surgery fellowships.
  • This method provides robust monitoring and reporting capabilities for fellow experiences, adaptable to other surgical subspecialties.
  • Efficient clinical documentation is crucial for surgeons, and this system offers a scalable solution for national acute care surgery fellowships.