The art of citation

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...

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.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:

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:

Laws form the essential rules set by governing authorities to shape and control societal behavior. In nursing, laws guide actions, safeguard patient rights, define nurses' scope of practice, and maintain professional standards. Understanding the legal framework governing nursing involves recognizing four primary sources of law: constitutional, statutory, administrative (regulatory), and common law.
Constitutional law is foundational, deriving from federal and state constitutions, and...

The innovation of touch-tone telephony revolutionized the telecommunications industry by replacing the traditional rotary dial with a dual-tone multi-frequency (DTMF) signaling system. This system uses a matrix-style keypad with buttons arranged in four rows and three columns, creating 12 distinct signals each assigned to a pair of frequencies. Each button press results in a simultaneous generation of two sinusoidal tones – one from a low-frequency group (697 to 941 Hz) and one from a...

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: