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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...
Nursing Clinical Information System01:27

Nursing Clinical Information System

Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Data Validation01:03

Data Validation

Data validation is an essential part of a comprehensive assessment. Validation is confirming or verifying and opening the door to gathering more assessment data as it clarifies vague or unclear data. The process of checking and verifying the collected information is called data validation. The primary purpose of data validation is to ensure data is as free from error, bias, and misinterpretation as possible.
Nursing assessment guides are generally based on holistic models rather than medical...
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...
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...

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Related Experiment Video

Updated: Jun 28, 2026

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation
04:58

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation

Published on: August 25, 2022

Concept mapping to develop a framework for characterizing Electronic Data Capture (EDC) Systems.

Alicia F Guidry1, James F Brinkley, Nicholas R Anderson

  • 1Division of Biomedical & Health Informatics and Institute for Translational Health Sciences, University of Washington, Seattle, WA, USA.

AMIA ... Annual Symposium Proceedings. AMIA Symposium
|November 13, 2008
PubMed
Summary

Clinical and Translational Science Awards (CTSAs) drive the need for improved electronic data capture (EDC) systems. A concept mapping framework was developed to evaluate EDCs for translational research data management needs.

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

Published on: September 20, 2018

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Last Updated: Jun 28, 2026

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation
04:58

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation

Published on: August 25, 2022

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

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

Published on: September 20, 2018

Area of Science:

  • Biomedical Informatics
  • Translational Science

Background:

  • Clinical and Translational Science Awards (CTSAs) have spurred demand for enhanced electronic data capture (EDC) systems.
  • Effective EDC systems are crucial for facilitating translational research.

Purpose of the Study:

  • To develop a framework for evaluating EDC systems based on specific clinical/translational research lab data management needs.
  • To characterize EDC systems currently utilized across CTSA sites nationally.

Main Methods:

  • Concept mapping was employed to create an EDC evaluation framework.
  • A spiral model approach was used for refinement, incorporating consultations with the University of Wisconsin CTSA.
  • A survey of other CTSAs was conducted to gather information on their EDC systems.

Main Results:

  • A validated framework for EDC system evaluation was established.
  • The study characterized the landscape of EDC systems used within CTSA institutions.
  • Identified key features and functionalities relevant to translational research data management.

Conclusions:

  • The developed framework provides a structured approach to assessing EDC systems for translational research.
  • Understanding current EDC usage across CTSAs can inform future system development and selection.
  • Optimizing EDC systems is essential for advancing translational research efficiency and data integrity.