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Related Concept Videos

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.
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,...
Guidelines and Strategies for Safe Computer Charting01:18

Guidelines and Strategies for Safe Computer Charting

The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Methods of Documentation I: Source-Oriented Records01:18

Methods of Documentation I: Source-Oriented Records

Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
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:
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...

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Related Experiment Video

Updated: Jul 11, 2026

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
09:00

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

Published on: April 13, 2021

Challenges and methodology for indexing the computerized patient record.

Frédéric Ehrler1, Patrick Ruch, Antoine Geissbuhler

  • 1Artificial Intelligence laboratory, University of Geneva, Geneva, Switzerland. ehrler@cui.unige.ch

Studies in Health Technology and Informatics
|October 4, 2007
PubMed
Summary

Indexing patient records presents scalability challenges. This study highlights overhead issues with current information retrieval tools, suggesting a need for specialized indexing solutions for efficient healthcare data management.

Related Experiment Videos

Last Updated: Jul 11, 2026

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
09:00

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

Published on: April 13, 2021

Area of Science:

  • Health Informatics
  • Information Retrieval
  • Computer Science

Background:

  • Patient records are vital for healthcare management.
  • Efficient retrieval of patient health information is crucial for care providers.
  • Current information retrieval (IR) tools face scalability challenges with patient record data.

Purpose of the Study:

  • To investigate the scalability issues in indexing and retrieving information from patient records.
  • To evaluate the performance of the EasyIR information retrieval tool in this context.

Main Methods:

  • Utilized EasyIR, an information retrieval tool, for full-text queries.
  • Analyzed the performance of indexing and retrieval processes.
  • Examined the impact of the unique structure of patient records on indexing.

Main Results:

  • The indexing process for patient records incurs significant overhead.
  • Existing IR tools, designed for large single indexes, are not optimal for a one-index-per-record approach.
  • The structure of patient records leads to performance inefficiencies.

Conclusions:

  • A specialized and efficient indexing tool is necessary for managing the high volume of daily patient record modifications and creations.
  • Current IR systems require adaptation or specialized solutions to handle the unique indexing demands of electronic health records.
  • Optimizing the indexing strategy is key to improving the speed and safety of accessing patient health information.