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Related Concept Videos

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...
Ultrasonography01:17

Ultrasonography

Ultrasonography is an imaging technique that uses high-frequency sound waves to visualize the body's internal structures. It is a non-invasive and safe procedure that does not involve the use of ionizing radiation, making it widely used in various medical fields. Ultrasonography is used to study heart function, blood flow in the neck or extremities, certain conditions such as gallbladder disease, and fetal growth and development.
During an ultrasonography procedure, a handheld device called a...
Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...
Imaging Studies II: Ultrasonography01:24

Imaging Studies II: Ultrasonography

IntroductionUltrasonography, or renal ultrasound, is a noninvasive medical imaging technique that uses high-frequency sound waves to visualize the kidneys, ureters, bladder, and surrounding tissues.Indications for Urinary System UltrasonographyUrinary system ultrasonography is indicated in various clinical scenarios, such as:Kidney Stones (Urolithiasis): To detect and monitor the size and presence of kidney or urinary tract stones.Hydronephrosis: To assess the dilation of the renal pelvis and...
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 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:

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Related Experiment Video

Updated: Jul 9, 2026

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies
10:38

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

Published on: January 16, 2019

Checking concordance between findings and diagnoses in sonographic reports by a knowledge-based documentation system.

M Huettig1, G Buscher, F Puppe

  • 1Clinic for Internal Medicine 2, DRK-Kliniken Berlin Köpenick.

Ultraschall in Der Medizin (Stuttgart, Germany : 1980)
|December 22, 2007
PubMed
Summary

Sonographic reports can be unreliable due to examiner dependence. A knowledge-based system (SonoConsult) improved consistency by checking documented findings against diagnostic conclusions, reducing discrepancies in ultrasound reports.

Related Experiment Videos

Last Updated: Jul 9, 2026

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies
10:38

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

Published on: January 16, 2019

Area of Science:

  • Medical Informatics
  • Diagnostic Imaging
  • Quality Improvement

Background:

  • Sonographic reports are subjective and examiner-dependent, potentially impacting diagnostic reliability.
  • Ensuring concordance between documented ultrasound findings and diagnostic conclusions is crucial for quality control.

Purpose of the Study:

  • To investigate the concordance between documented sonographic findings and diagnostic conclusions using a knowledge-based documentation system.
  • To assess the reliability and consistency of ultrasound reports by comparing physician diagnoses with system-generated inferences.

Main Methods:

  • Utilized the SonoConsult (SC) knowledge-based system for routine documentation in a gastroenterological clinic's ultrasound unit.
  • Compared physician-documented diagnoses (free text) with SC-inferred diagnoses based on structured findings.
  • Manually reviewed discrepancies, classifying them by clinical relevance and inferential complexity.

Main Results:

  • In the first series (250 cases), 71.1% agreement was found; 24.4% of diagnoses were false negatives (physician missed) and 4.5% were false positives.
  • In the second series (161 cases), agreement dropped to 61.1%, with 36.1% false negatives and 2.8% false positives.
  • Higher clinical relevance and complexity of diagnoses correlated with increased rates of missed findings.

Conclusions:

  • Discrepancies between documented sonographic findings and diagnostic conclusions are common and require attention.
  • Detailed finding documentation is essential for quality control.
  • Automated consistency checks within electronic patient records can significantly enhance the quality of sonographic reports.