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Related Concept Videos

Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

1.0K
The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...
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Formats for Nursing Documentation01:28

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Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
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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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Methods of Documentation III: PIE01:21

Methods of Documentation III: PIE

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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:
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Methods of Documentation IV: Focus Charting01:26

Methods of Documentation IV: Focus Charting

1.9K
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:
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Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

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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.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
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Related Experiment Video

Updated: Apr 12, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

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Strategies to Formulate, Present, and Document Complex Cases and Avoid Critical Omissions.

Anita K Chang1,2, Patrick A Ho3,4, James K Rustad3,5,6,7

  • 1Ohio State University, Columbus, Ohio.

The Primary Care Companion for CNS Disorders
|April 10, 2026
PubMed
Summary

This service aids medical and surgical inpatients with psychiatric conditions. Rounds reports offer valuable insights for physicians at the medicine-psychiatry interface.

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Area of Science:

  • Psychiatry and Medicine
  • Inpatient Consultation Services

Background:

  • Medical and surgical inpatients frequently present with comorbid psychiatric symptoms.
  • Managing complex cases requires interdisciplinary collaboration.

Purpose of the Study:

  • To summarize key diagnostic and management discussions from a psychiatric consultation service.
  • To provide practical guidance for clinicians managing patients at the medicine-psychiatry interface.

Main Methods:

  • Review of twice-weekly rounds discussions from a hospital-based Psychiatric Consultation Service.
  • Case-based analysis of diagnosis and management strategies for complex inpatients.

Main Results:

  • Identification of common psychiatric presentations in medical/surgical inpatients.
  • Development of practical approaches for managing comorbid conditions.

Conclusions:

  • Psychiatric consultation services are crucial for optimizing care in complex inpatients.
  • Rounds reports can serve as valuable educational tools for clinicians.