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Related Concept Videos

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

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Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
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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.
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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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Related Experiment Video

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Digital Quality Resources Resulting from Standardized Program for Rubric Training in Medical Residents.

María Valeria Jiménez Báez1, María Erika Gutiérrez De la Cruz1, María Margarita Chávez Hernández1

  • 1Coordination of Planning and Institutional Link, Mexican Institute of Social Security in Quintana Roo, Cancun 77533, Mexico.

Healthcare (Basel, Switzerland)
|November 11, 2022
PubMed
Summary

A digital training program using rubrics improved health residents' research skills and educational quality. This standardized approach enhanced resident performance, regardless of prior publication experience.

Keywords:
distance educationhealth personnelprogram evaluationresidency educationrubricsscoringspecialty

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Area of Science:

  • Medical Education
  • Health Professions Education
  • Research Skills Development

Background:

  • Healthcare education requires robust assessment tools to validate resident competency.
  • Standardized training programs are crucial for skill acquisition in medical specialties.

Purpose of the Study:

  • To evaluate the impact of a standardized digital training program with rubrics on the quality of resident research resources.
  • To assess improvements in medical residents' research skills and overall educational experience.

Main Methods:

  • Prospective observational study involving 85 first-year medical residents across seven specialties and four centers.
  • Utilized a b-learning format with validated rubrics assessing research methodology, initial/final evaluations, colloquium, and a 360-degree satisfaction survey.
  • Quality was scaled using five dimensions, with global values >80 considered good; Delphi method validated instruments (agreement ≥0.8).

Main Results:

  • Residents achieved a mean quality score of 80.62 (±9.59), with 82.5% reporting excellent/good satisfaction.
  • A positive correlation was found between evaluation scope and satisfaction levels.
  • No significant relationship existed between prior research experience and final average scores (r=0.123, p=0.291).

Conclusions:

  • Implementing b-learning research seminars with a rubric system enhances health residents' education and research skills.
  • The training program improved the quality of residents' final research output, even for those with no prior publication experience.
  • Digital training and structured evaluation are effective in advancing resident competency in healthcare research.