An Examination of Self-Reported Assessment Activities Documented by Specialist Physicians for Maintenance of

Jocelyn Lockyer1, Shanna DiMillo, Craig Campbell

  • 1Dr. Lockyer: Professor, Department of Community Health Sciences, Cumming School of Medicine, Calgary, Canada. Ms. DiMillo: Senior Data and Research Analyst, Health Policy and Advocacy, Royal College of Physicians and Surgeons of Canada, Ottawa, Canada. Dr. Campbell: Principal Senior Advisor, Competency-based CPD and interim Director, Continuing Professional Development, Office of Specialty Education, Royal College of Physicians and Surgeons of Canada, and Associate Professor, Department of Medicine, University of Ottawa, Ottawa, Canada.

Abstract

Related Concept Videos

Data Collection III01:05

Data Collection III

The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.
The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the...
3.8K
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...
1.3K
Chronic Obstructive Pulmonary Disease-IV: Assessement and Diagnostic Studies01:27

Chronic Obstructive Pulmonary Disease-IV: Assessement and Diagnostic Studies

Assessing and diagnosing Chronic Obstructive Pulmonary Disease (COPD) involves a detailed approach that includes a comprehensive review of medical history, physical examination, and a variety of diagnostic tests. This thorough evaluation is essential to ensure an accurate diagnosis and guide effective management strategies.
Medical History
3.0K
Assessment of the Cardiovascular System I: Subjective Data01:23

Assessment of the Cardiovascular System I: Subjective Data

A thorough health history and physical assessment are essential for identifying cardiovascular disease (CVD) symptoms and distinguishing them from other health issues.
Initial Enquiry
Ask the patient about their primary concern and thoroughly explore all reported symptoms.
Medical History
Investigate past illnesses affecting the cardiovascular system, such as angina, anemia, rheumatic fever, congenital heart disease, stroke, thrombophlebitis, dysrhythmias, varicosities
Inquire about symptoms...
693
Assessment of Respiration01:23

Assessment of Respiration

The respiratory system's basic structures and primary functions lay the foundation for nurses' comprehensive respiratory assessments. This assessment includes subjective and objective data to gauge the patient's respiratory health.
Subjective Assessment: Nurses interview the patient to gather information directly during the subjective assessment. It includes questions about the individual's medical history, medications, and symptoms, focusing on past respiratory conditions like...
1.7K
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:
957