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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.
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Purpose of Health Records I01:11

Purpose of Health Records I

The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:
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Standards of Care II01:19

Standards of Care II

Nurses bear specific legal responsibilities under several federal statutes, including:
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Accountability and Responsibility of a Nurse II01:09

Accountability and Responsibility of a Nurse II

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.
For example, a nurse demonstrating respect and compassion might listen attentively to a patient's concerns, provide...
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Healthcare Associated Infections II: Preventive Measures01:22

Healthcare Associated Infections II: Preventive Measures

Essential infection prevention measures are based on the knowledge of the infection chain, the modes of transmission in healthcare settings, and the use of the best practices in all healthcare settings. Compulsory public reporting of healthcare-associated infection rates is needed to allow individuals and the community to make informed choices regarding selecting a healthcare facility.
The best practices for preventing healthcare-associated infections include hand hygiene, patient risk...
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PPE Use in Healthcare Settings I: Donning01:22

PPE Use in Healthcare Settings I: Donning

Donning PPE must be completed before contact with the patient. This process protects from infectious agents. The sequence and action included in each donning are critical, and the steps must be systematic to avoid exposure to pathogens. The institutional policy also needs to be followed while donning PPE. The pre-donning preparations are gathering equipment, inspecting the PPE equipment for tears, holes, or damage, removing jewelry, removing any garments below the elbows, and tying the hair...
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