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Methods of Documentation V: CBE

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...

The Professional Nurse

The Professional Nurse

Professional nurses are not limited to bedside care and are taking roles of greater responsibility. A nurse should have a knowledge-based practice, including personal, theoretical, procedural, cultural, and reflexive knowledge. Additionally, nurses must be competent in cognitive, technical, interpersonal, and ethical/legal skills. Some of the best attributes of successful nurses include the following:
Communication skills: These are critical characteristics, especially speaking and listening.

Methods of Documentation VII: EMR

Methods of Documentation VII: EMR

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...

Methods of Documentation II: POMR

Methods of Documentation II: POMR

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: May 10, 2025

Author Spotlight: Demonstrating Systematic Endobronchial Ultrasound to New Endoscopists

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Published on: August 11, 2023

[COMPETENCE BASED MEDICAL EDUCATION].

¹Department of Obstetrics and Gynecology, Barzilai Medical Center, Ben Gurion University of the Negev, The Israeli Medical Scientific Committee.

|April 21, 2025

Summary

This summary is machine-generated.

Medical education shifted from time-based learning to competency-based medical education (CBME) focusing on mastery and learner-centered approaches. This redefined the doctor

Area of Science:

Medical Education
Curriculum Development
Healthcare Professional Training

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