Chart review skills: a dimension of clinical competence

Journal of Medical Education
|October 1, 1979
PubMed

Related Concept Videos

Patient-centered Care01:13

Patient-centered Care

Patient-centered care involves delivering care beyond inpatient hospitalization. Reflective practice can enhance a patient-centered approach. Reflective practice is a process of reasoning that considers all aspects of the present situation, including practicalities, learning from personal practice, and consideration of patient needs. Patients appreciate care decisions made while considering their input. Involving the patient in their care provides the patient with a sense of contribution rather...
Critical Thinking II01:25

Critical Thinking II

Critical thinking is a cognitive process with several attributes. The attributes of critical thinking include the following:
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:
Methods of Documentation V: CBE01:23

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...
Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

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 illness...
Interpreting R Charts01:22

Interpreting R Charts

R chart, or range chart, is a fundamental tool in statistical process control used to monitor the variability within a process. It complements the X-bar (x̄) chart by focusing on the range of the data, rather than individual values, providing a clear picture of the process dispersion over time.
An R chart plots the range of subsets of measurements collected from a process. Each point on the chart represents the range—defined as the difference between the maximum and minimum values—of a sample...