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Related Concept Videos

Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

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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...
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Nursing Clinical Information System01:27

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Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
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Methods of Documentation III: PIE01:21

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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:
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Guidelines for Writing Outcome01:11

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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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Methods of Documentation II: POMR01:26

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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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Methods of Documentation IV: Focus Charting01:26

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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:
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Related Experiment Video

Updated: Jan 3, 2026

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies
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Turning Objective Structured Clinical Examinations into Reality.

Lisa Criscione-Schreiber1

  • 1Division of Rheumatology and Immunology, Program for Women in Internal Medicine, Department of Medicine, Duke University School of Medicine, Box 3490 DUMC, 40 Duke Medicine Circle, Durham, NC 27710, USA.

Rheumatic Diseases Clinics of North America
|November 24, 2019
PubMed
Summary

Objective structured clinical examinations (OSCEs) effectively assess clinical skills and provide valuable formative feedback for rheumatology trainees. Well-designed OSCEs enhance medical education for both learners and educators.

Keywords:
Clinical assessmentCommunicationEducationOSCEObserved structured clinical examinationSimulation

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Area of Science:

  • Medical Education
  • Clinical Assessment

Background:

  • Objective structured clinical examinations (OSCEs) are used to evaluate clinical performance.
  • OSCEs can serve as both summative and formative assessments.

Purpose of the Study:

  • To review the application of OSCEs in rheumatology education.
  • To outline the process of creating OSCEs.
  • To discuss the benefits and potential drawbacks of OSCEs.

Main Methods:

  • Literature review on the use of OSCEs in rheumatology.
  • Discussion of OSCE design, validity, and reproducibility.
  • Analysis of educational benefits and hazards.

Main Results:

  • OSCEs are valuable for assessing clinical skills in rheumatology.
  • Immediate feedback during OSCEs enhances learning.
  • Careful design is crucial for validity and reproducibility.

Conclusions:

  • Formative OSCEs offer significant educational value in rheumatology.
  • OSCEs can improve learner performance and teaching methods.