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Methods of Documentation VII: EMR

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,...

Methods of Documentation I: Source-Oriented Records

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 V: CBE

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 Model

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...

Methods of Documentation II: POMR

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 III: PIE

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:

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Modeling Biological Membranes with Circuit Boards and Measuring Electrical Signals in Axons: Student Laboratory Exercises

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Published on: January 18, 2011

Modeling electronic documentation as a communication system.

Jane M Carrington¹, Judith A Effken

¹The University of Arizona, Tucson, AZ, USA.

AMIA ... Annual Symposium Proceedings. AMIA Symposium

|August 13, 2008

Summary

This summary is machine-generated.

This study introduces a new research model for evaluating electronic documentation

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Published on: January 18, 2011

Constructing and Visualizing Models using Mime-based Machine-learning Framework

Constructing and Visualizing Models using Mime-based Machine-learning Framework

Published on: July 22, 2025

Area of Science:

Health Informatics
Communication Studies

Background:

Electronic documentation is crucial in modern healthcare communication.
Existing models may not fully capture the nuances of electronic documentation systems.

Purpose of the Study:

To present a novel research model for studying electronic documentation effectiveness.
To adapt established communication and informatics models for this purpose.

Main Methods:

The proposed model integrates elements from Gerbner's General Communication Model.
It also incorporates principles from Effken's Informatics Research Organizing Model (IROM).

Main Results:

The model illustrates key events in the electronic documentation communication process.
It clarifies the relationships between these communication events.

Conclusions:

This new model offers a structured approach to analyzing electronic documentation.
It provides a framework for future research on communication systems in healthcare.