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Related Concept Videos

Legal Guidelines for Documentation01:06

Legal Guidelines for Documentation

The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
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 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...
Types of Records II: Educational and Administrative Records01:18

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:
Formats for Nursing Documentation01:28

Formats for Nursing Documentation

Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...

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Related Experiment Video

Updated: May 9, 2026

Universal Screening for Prevention of Reading, Writing, and Math Disabilities in Spanish
14:43

Universal Screening for Prevention of Reading, Writing, and Math Disabilities in Spanish

Published on: July 18, 2020

Document holder usage when reading and writing.

R Burgess1, R J Neal

  • 1Department of Human Movement Studies, University of Queensland, Australia.

Clinical Biomechanics (Bristol, Avon)
|August 7, 2013
PubMed
Summary
This summary is machine-generated.

Using a document holder while notetaking significantly improved neck posture and comfort. This ergonomic aid reduced neck strain by decreasing the moment of the head and neck about C7-T1, making it a beneficial tool for improving working posture.

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Digital Handwriting Analysis of Characters in Chinese Patients with Mild Cognitive Impairment
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Universal Screening for Prevention of Reading, Writing, and Math Disabilities in Spanish
14:43

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Published on: July 18, 2020

Digital Handwriting Analysis of Characters in Chinese Patients with Mild Cognitive Impairment
05:58

Digital Handwriting Analysis of Characters in Chinese Patients with Mild Cognitive Impairment

Published on: March 11, 2021

Area of Science:

  • Ergonomics
  • Biomechanics
  • Occupational Health

Background:

  • Poor working posture during notetaking can lead to discomfort and strain.
  • The use of document holders is a common ergonomic intervention.

Purpose of the Study:

  • To investigate the effects of a document holder on head and neck posture during notetaking.
  • To assess subjective comfort levels associated with document holder use.

Main Methods:

  • Twelve subjects performed notetaking for 20 minutes with and without a 29° inclined document holder.
  • Photographs were taken every 5 minutes to analyze posture.
  • Moments of the head and neck were calculated relative to body mass (BM).

Main Results:

  • The neck was inclined significantly more vertically when using the document holder (P < 0.001).
  • The moment of the head and neck about C7-T1 was significantly reduced with the document holder (P < 0.01).
  • Subjects significantly preferred using the document holder (P < 0.5).

Conclusions:

  • Document holder use positively influences working posture during notetaking.
  • Reduced neck moment is hypothesized to be the reason for increased comfort.
  • Environmental modifications, like document holders, can be beneficial for improving posture.