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Methods of Documentation II: POMR

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 III: PIE

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:

Methods of Documentation IV: Focus Charting

Methods of Documentation IV: Focus Charting

Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:

Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation

Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation

Evaluation of the teaching process enables the nurse to determine if the patient's learning needs were met and if training was effective. If the expected outcomes are not met, the care plan is revised, and additional education or reinforcement is provided. Nurses can ask questions after the session or obtain feedback to assess the patient's understanding of the topic.
Nurses can use several methods to evaluate patient outcomes. For example, oral questions can assess cognitive learning,...

Nursing Evaluation

Nursing Evaluation

The evaluation stage signals the end of the nursing process. The nurse gathers evaluative data to assess whether or not the patient has attained the expected results. Whereas the nurse collects data in the nursing assessment to identify the patient's health concerns, the evaluation stage data determines if the indicated health issues are resolved. Evaluative data collection includes two sections: the data acquired to evaluate patient outcomes and the time criteria for data collection.

Guidelines for Writing Outcome

Guidelines for Writing Outcome

When developing expected outcomes for a patient care plan, the nurse should adhere to the following recommendations:
Patient outcomes reflect the patient's response to the goal rather than what the nurse aims to achieve. Terminology should be observable and measurable to avoid the reader's interpretation. The desired outcome should be realistic and achievable in the designated care timeframe. Expected outcomes should align with adjunctive therapies. The outcome should enhance care...

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Implementation of Non-invasive Point of Care Transient Elastography for Evaluation of Liver Disease in Pediatric Populations with Cystic Fibrosis

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Done or Almost Done? Improving OSCE Checklists to Better Capture Performance in Progress Tests.

Debra Pugh¹, Samantha Halman¹, Isabelle Desjardins¹

¹a Department of Medicine , University of Ottawa, The Ottawa Hospital , Ottawa , Ontario , Canada.

Teaching and Learning in Medicine

|October 5, 2016

Summary

Nonbinary checklists in objective structured clinical examination (OSCE) progress tests showed scoring method differences. The hawk, dove, and hybrid methods impacted resident scores and pass-fail rates, varying by exam type.

Keywords:

OSCE Progress test assessment checklist

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Area of Science:

Medical Education
Assessment in Medicine
Clinical Skills Evaluation

Background:

Objective Structured Clinical Examination (OSCE) progress tests assess learners across different training levels.
Traditional OSCEs often use rating instruments that may not fully capture performance variations in progress tests.
Nonbinary checklists were introduced to better evaluate performance in OSCE progress tests.

Purpose of the Study:

To identify how task type influences the use of nonbinary checklist options (done satisfactorily, attempted, not done).
To analyze the impact of different scoring methods (hawk, dove, hybrid) on nonbinary checklists in procedural and nonprocedural OSCE progress tests for Internal Medicine residents.
To determine the most suitable scoring method for specific task types within OSCE progress tests.

Main Methods:

Retrospective analysis of scores from 119 participants in two OSCE progress tests (procedural and nonprocedural).
Comparison of three scoring methods (hawk, dove, hybrid) varying in stringency for nonbinary checklist items.
Evaluation of difficulty, reliability (internal consistency), item-total correlations, and pass rates for each scoring method and OSCE type.

Main Results:

Mean OSCE scores were highest with the dove method and lowest with the hawk method.
The hawk method yielded higher item-total correlations, with variations by task type.
Pass-fail status significantly differed based on scoring methods and exam type, with higher failure rates observed for nonprocedural OSCEs using hawk/hybrid methods and for procedural OSCEs using the dove method.

Conclusions:

Different scoring methods applied to nonbinary OSCE checklists lead to variations in mean scores and pass-fail outcomes.
The effectiveness and impact of scoring methods are dependent on whether the OSCE progress test is procedural or nonprocedural.