相关实验视频

Updated: Jul 27, 2025

Improving IV Insulin Administration in a Community Hospital
12:08

Improving IV Insulin Administration in a Community Hospital

Published on: June 11, 2012

18.9K

你的笔记,你的方式:如何准确和高效地作为实习生撰写住院病人的进度笔记

Miao Wei1, Efrain Salgado2, Christine E Girard3

  • 1Internal Medicine, Cleveland Clinic Florida, Weston, Florida, USA.

Postgraduate medical journal
|June 9, 2023
PubMed
概括

通过实用建议和一个新的模板方法来改进医生进展记录,以实现高效的电子健康记录文档. 本指南增强了医疗住院人员的沟通和患者护理质量.

关键词:
内部医学是内科的专业.医学教育和培训 医学教育和培训

更多相关视频

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit06:52

Assessment of Dependence in Activities of Daily Living Among Older Patients in an Acute Care Unit

Published on: September 30, 2020

9.9K
Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies10:38

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Published on: January 16, 2019

20.3K

相关概念视频

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.
1.0K
Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
1.1K
Methods of Documentation III: PIE01:21

Methods of Documentation III: PIE

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:
1.4K
Data Reporting and Recording01:24

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
4.8K
Legal Guidelines for Documentation01:06

Legal Guidelines for Documentation

The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
1.3K
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:  
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
1.1K