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Related Concept Videos

Types of Reports III: Telephone and Verbal Reports01:26

Types of Reports III: Telephone and Verbal Reports

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Telephone and Verbal Reports in healthcare settings are two communication methods for conveying therapeutic instructions from healthcare providers to nurses or other healthcare staff.
Here's an overview of each type:
Telephone Orders
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Types of Reports I: Hands-off Report01:25

Types of Reports I: Hands-off Report

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A hand-off report, also known as a change-of-shift report, is a crucial nursing process that ensures the smooth transition of patient care responsibilities between nursing staff.
Following are the key components and categories of hand-off reports:
Purpose and Process:
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Types of Reports II: Incident or Occurrence Report01:21

Types of Reports II: Incident or Occurrence Report

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An Incident or Occurrence Report in a healthcare setting is a crucial document used to record any unexpected occurrence that may or may not have affected a patient, employee, or visitor. Such reports are critical to improving patient safety and include all details leading up to and including the event.
Purposes:
In the healthcare industry, reports play a crucial role in documenting incidents within an agency. The primary objective of these reports is to ensure patient safety, uphold the...
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Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

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Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
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Methods of Documentation I: Source-Oriented Records01:18

Methods of Documentation I: Source-Oriented Records

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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.
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:
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Methods of Documentation II: POMR01:26

Methods of Documentation II: POMR

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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

Updated: Jun 4, 2025

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
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Guidance on reporting the use of natural language processing methods

Ran Gilad-Bachrach1, Uri Obolski2

  • 1Department of Biomedical Engineering, Tel-Aviv University, Tel-Aviv, Israel; Edmond J. Safra Center for Bioinformatics, Tel Aviv University, Tel-Aviv, Israel.

Clinical Microbiology and Infection : the Official Publication of the European Society of Clinical Microbiology and Infectious Diseases
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No abstract available in PubMed .

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