J K Stross1, T J DeKornfeld

  • 1Department of Internal Medicine, University of Michigan Medical School, Ann Arbor 48109-0368.

JAMA
|November 14, 1990
PubMed
まとめ

ミシガン州の医師は,一般的に継続医療教育 (CME) の時間要件を満たしていましたが,多くは文書化に苦労しました. 監査では,記録の保存に関する問題が明らかになり,CMEのコンプライアンスに関するより明確なガイドラインと参加者への通知の必要性を示唆しました.

関連する概念動画

Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation01:20

Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation

Evaluation of the teaching process enables the nurse to determine if the patient's learning needs were met and if training was effective. If the expected outcomes are not met, the care plan is revised, and additional education or reinforcement is provided. Nurses can ask questions after the session or obtain feedback to assess the patient's understanding of the topic.
Nurses can use several methods to evaluate patient outcomes. For example, oral questions can assess cognitive learning, patient...
Types of Records II: Educational and Administrative Records01:18

Types of Records II: Educational and Administrative Records

Maintaining nurses' educational and administrative records in healthcare settings, including hospitals and nursing schools, is paramount. Here's a breakdown of the types of academic records mentioned:
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 VII: EMR01:30

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 settings,...
Standards of Care II01:19

Standards of Care II

Nurses bear specific legal responsibilities under several federal statutes, including:
Accountability and Responsibility of a Nurse I01:30

Accountability and Responsibility of a Nurse I

Accountability in nursing is a fundamental principle that underscores the obligation of nurses to take responsibility for their actions and answer for any errors or omissions in patient care. This principle is grounded in the professional, legal, and ethical frameworks that shape nursing practice. For instance, nurses must adhere to all relevant laws, regulations, and practice standards, including guidelines set forth by nursing boards and professional bodies, to ensure their actions comply...