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Related Concept Videos

Methods of Documentation III: PIE01:21

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 Reporting and Recording01:24

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
Data Collection III01:05

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.
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:  
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
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.
Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.

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LETTER TO THE EDITOR REGARDING: Torrens C, González-García C, Díez-Izquierdo M, Santana F. Three-week immobilization vs. no immobilization in primary reverse total shoulder arthroplasty: a randomized controlled trial. J Shoulder Elbow Surg. 2025 Nov;34(11):2543-2549. doi:10.1016/j.jse.2025.02.015.

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Is There a Long-Term Benefit to use Patient-Specific Guides for Glenoid Implant Positioning in aTSA? A comparative study at minimum 10 years.

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''The Global Glenoid Component Inclination: why scapulothoracic orientation should be considered when defining glenoid component inclination in reverse total shoulder arthroplasty''.

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Related Experiment Video

Updated: May 18, 2026

Collecting Sleep, Circadian, Fatigue, and Performance Data in Complex Operational Environments
08:36

Collecting Sleep, Circadian, Fatigue, and Performance Data in Complex Operational Environments

Published on: August 8, 2019

Patient diary helps assessment

D H Sonnabend1

  • 1The Prince of Wales Hospital Rondwick, New South Wales, Australia.

Journal of Shoulder and Elbow Surgery
|September 11, 2012
PubMed
Summary

No abstract available in PubMed .

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