Related Concept Videos
01:30Methods 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,...
01:26Methods 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.
01:30Health Information Technology and Healthcare Information System
Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
01:21Methods 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:
01:18Methods 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:
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:
01:15Methods 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...
For example, a patient with a chronic illness...
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Same system, different outcomes: comparing the transitions from two paper-based systems to the same computerized
Zahra Niazkhani1, Heleen van der Sijs, Habibollah Pirnejad
1Institute of Health Policy and Management (iBMG), Erasmus University Medical Center, Rotterdam, The Netherlands. z.niazkhani@erasmusmc.nl
International Journal of Medical Informatics
|September 2, 2008
Summary
Nurses using a computerized physician order entry (CPOE) system perceived its impact differently based on their prior paper system. Differences in work structure significantly influenced user perceptions of CPOE implementation.
Area of Science:
- Health Informatics
- Nursing Practice
- Human-Computer Interaction
Background:
- Electronic health records and CPOE systems are increasingly adopted in healthcare.
- Understanding user perception is crucial for successful technology implementation.
- Previous work structures can influence how users adapt to new systems.
Purpose of the Study:
- To compare nurse perceptions of a CPOE system's impact on medication activities.
- To investigate how different pre-implementation paper-based systems affect CPOE adoption.
- To analyze the influence of work structure changes on user experience.
Main Methods:
- A questionnaire survey was administered to nurses before and after CPOE implementation.
- Nurses were categorized based on their prior use of either the Kardex or TIMED paper system.
- Adaptive Structuration Theory (AST) was employed to interpret findings.
Main Results:
- Nurses previously using the Kardex system reported more positive CPOE effects than those using the TIMED system.
- TIMED-system users found the CPOE less flexible, harder to use, and slower.
- Despite increased overall satisfaction, neither group reported improved workflow support with CPOE compared to paper systems.
Conclusions:
- Significant differences in pre- and post-implementation work structures heavily influence user perceptions of CPOE systems.
- Greater user satisfaction with a new system does not automatically equate to better workflow support.
- System implementation success is contingent on both technology design and the degree of work structure adaptation.