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Updated: Jun 28, 2026

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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
Methods for building sense inventories of abbreviations in clinical notes
Hua Xu1, Peter D Stetson, Carol Friedman
1Department of Biomedical Informatics, Columbia University, New York, NY, USA.
AMIA ... Annual Symposium Proceedings. AMIA Symposium
|November 13, 2008
Abstract
No abstract available in PubMed .
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Guidelines for Nursing Documentation I
Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
Mnemonic Devices
Mnemonic devices are cognitive tools that facilitate memory retention by linking new information to familiar patterns or organizational strategies. These techniques are beneficial for remembering complex or lengthy sets of information by simplifying and structuring them in easily retrievable ways.
Acronyms
Acronyms are created by using the initial letters of a series of words to form a new word or phrase. This approach condenses complex information into a single, memorable entity. For example,...
Acronyms
Acronyms are created by using the initial letters of a series of words to form a new word or phrase. This approach condenses complex information into a single, memorable entity. For example,...
Data Reporting and Recording
Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
SBAR I: Understanding the Concept
Effective communication among healthcare professionals during hand-off reporting is essential to delivering safe and continuous patient care. Common professional interactions include reports to healthcare team members, hand-off, and transfer reports. Nurses routinely report information to other healthcare team members and also urgently contact healthcare providers to report changes in patient status.
Standardized methods of communication have been developed to ensure that information is...
Standardized methods of communication have been developed to ensure that information is...
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:
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: 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:

