From "Difficult" to Descriptive

Sara Kaylor1

  • 1Sara Kaylor is assistant dean for accreditation and evaluation at the University of Alabama Capstone College of Nursing in Tuscaloosa, AL. Contact author: skkaylor@ua.edu. The author has disclosed no potential conflicts of interest, financial or otherwise.

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Classification of Illness01:17

Classification of Illness

The meaning of illness is individualized to each person who experiences an alteration in health. In contrast, disease is a medical term indicating a pathological change in the structure and function of the body or mind. It is a condition that has specific symptoms and boundaries.
An illness is a response to a disease in which the person's level of functioning is changed compared with a previous level. The general classification of illness includes acute and chronic.
Acute illness is severe and...
Methods of Documentation II: POMR01:26

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.
Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
Methods of Documentation IV: Focus Charting01:26

Methods of Documentation IV: Focus Charting

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:
Directional Terms01:14

Directional Terms

Directional terms are essential for describing the relative locations of different body structures. For instance, an anatomist might describe one band of tissue as "inferior to" another, or a physician might describe a tumor as "superficial to" a deeper body structure. These terms often use comparative terms in pairs to trace out the relative locations of one body part to another or descriptions of body tissues like the deeper ones from superficially present with reference to the body's upright...
Problem Solving: Dimensional Analysis01:08

Problem Solving: Dimensional Analysis

Every mathematical equation that connects separate distinct physical quantities must be dimensionally consistent, which implies it must abide by two rules. For this reason, the concept of dimension is crucial. The first rule is that an equation's expressions on either side of an equality must have the exact same dimension, i.e., quantities of the same dimension can be added or removed. The second rule stipulates that all popular mathematical functions, such as exponential, logarithmic, and...