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Related Concept Videos

Chronic Obstructive Pulmonary Disease-III: Symptoms and Complications.01:25

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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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Hospitals provide inpatient and outpatient services. Inpatient services provide care to patients that stay in the hospital for an extended period, ranging from days to months. Examples of inpatient services include intensive care units, hospital wards, or surgeries. Outpatient services provide care to patients who come to a hospital for a diagnostic or treatment but do not stay overnight —for example, diagnostic tests, surgical procedures, or health education.
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When developing expected outcomes for a patient care plan, the nurse should adhere to the following recommendations:
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Heart failure (HF) manifests primarily as dyspnea, fatigue, and fluid retention, resulting in peripheral and pulmonary edema. Symptoms may vary depending on which ventricle is more affected, left or right.Left-Sided Heart FailureAlso known as left ventricular failure, this condition results from the left ventricle's inability to fill or eject sufficient blood into the systemic circulation. It leads to pulmonary congestion, which occurs when the left ventricle fails to eject blood effectively...
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Methods of Documentation I: Source-Oriented Records01:18

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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.
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Common Symptoms in Outpatient Practice

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