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Related Concept Videos

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,...
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...
Formats for Nursing Documentation01:28

Formats for Nursing Documentation

Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
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:
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:
Flow Sheet01:17

Flow Sheet

Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:

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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
07:50

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Published on: September 20, 2018

Assessing usage patterns of electronic clinical documentation templates.

David K Vawdrey1

  • 1Department of Biomedical Informatics, Columbia University, New York, NY, USA.

AMIA ... Annual Symposium Proceedings. AMIA Symposium
|November 13, 2008
PubMed
Summary
This summary is machine-generated.

Electronic medical record (EMR) templates enhance clinical documentation. A study tracked template availability and usage across two academic medical centers, revealing significant variation in adoption rates and identifying the most frequently used templates.

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Area of Science:

  • Health Informatics
  • Clinical Documentation Improvement
  • Electronic Medical Records (EMR)

Background:

  • Electronic medical record systems commonly offer configurable templates for structured and free-text clinical document entry.
  • Optimizing template utilization is crucial for efficient clinical workflows and data standardization within healthcare institutions.

Purpose of the Study:

  • To assess the availability and usage patterns of electronic documentation templates across two large academic medical centers.
  • To identify trends in template adoption and utilization over a defined period.

Main Methods:

  • Development of a documentation management data mart and a web-accessible business intelligence application.
  • Tracking template availability and usage data from November 2007 to February 2008.
  • Analysis of approximately 65,000 weekly authored electronic notes per center.

Main Results:

  • Significant disparities in template utilization were observed between the two medical centers.
  • One center had 934 templates available, with 313 (33.5%) in use, while the other had 765 available, with 480 (62.7%) in use.
  • The 'Miscellaneous Nursing Note' (free text) was the most commonly used template at both sites, accounting for 33.3% and 15.2% of total documents.

Conclusions:

  • Template availability does not directly correlate with usage, indicating potential barriers to adoption or suboptimal template design.
  • Further investigation is needed to understand factors influencing template utilization and to promote more comprehensive use of available EMR documentation tools.
  • Standardized EMR template implementation strategies may improve documentation efficiency and data quality across healthcare systems.