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Types of Records II: Educational and Administrative Records

Maintaining nurses' educational and administrative records in healthcare settings, including hospitals and nursing schools, is paramount. Here's a breakdown of the types of academic records mentioned:
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Self-Evaluation Maintenance Model

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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.
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Professional accountability in nursing is a multifaceted concept that encompasses professional ethics, legal standards, and employment expectations. This framework ensures that nurses maintain and elevate the quality of care while upholding the values of their profession. It compels them to treat patients, families, and colleagues with respect, compassion, and integrity.
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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.

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Related Experiment Video

Updated: May 13, 2026

A Computerized Functional Skills Assessment and Training Program Targeting Technology Based Everyday Functional Skills
07:31

A Computerized Functional Skills Assessment and Training Program Targeting Technology Based Everyday Functional Skills

Published on: February 13, 2020

Demystifying maintenance of certification.

Richard N Nelson1

  • 1Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, OH.

Annals of Emergency Medicine
|March 16, 2013
PubMed
Summary
This summary is machine-generated.

The American Board of Emergency Medicine (ABEM) requires continuous professional development and quality improvement for its Maintenance of Certification (MOC) program. Physician participation in ABEM MOC is reviewed.

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Published on: January 20, 2019

Area of Science:

  • Medical Education
  • Emergency Medicine
  • Professional Certification

Background:

  • Board certification in medical specialties began in 1908, with the American Board of Medical Specialties (ABMS) established in 1933.
  • Emergency medicine was recognized as the 23rd medical specialty by the ABMS in 1979.
  • The American Board of Emergency Medicine (ABEM) has historically required time-limited certification with recertification every 10 years.

Purpose of the Study:

  • To define the components of the ABEM Maintenance of Certification (MOC) program.
  • To discuss the core principles of ABEM MOC, including continuous professional development and quality improvement.
  • To review physician engagement with the ABEM MOC program.

Main Methods:

  • Review of the American Board of Emergency Medicine (ABEM) Maintenance of Certification (MOC) program structure.
  • Analysis of MOC program axioms: continuous professional development and quality development.
  • Examination of physician participation data within the ABEM MOC framework.

Main Results:

  • The ABEM MOC program is structured around continuous professional development and adherence to quality improvement.
  • Specific components of the ABEM MOC program are detailed.
  • Physician participation trends in the ABEM MOC program are presented.

Conclusions:

  • The ABEM MOC program ensures ongoing competency and quality in emergency medicine.
  • Continuous professional development and quality improvement are central tenets of ABEM MOC.
  • Understanding physician participation is key to the MOC program's effectiveness.