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Related Concept Videos

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...
Methods of Documentation II: POMR01:26

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 VI: Case Management Model01:15

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...
Formulating and Validating Nursing Diagnosis I01:26

Formulating and Validating Nursing Diagnosis I

A nursing diagnosis is written when the nurse recognizes a cluster of essential patient data indicating health problems treated with independent nursing interventions. The standardized terminologies of a nursing diagnosis help nurses identify and treat patients' problems. Every electronic health record that uses nursing diagnosis must employ standard diagnostic terminology. Developing an efficient, individualized care plan begins with accurate nursing diagnoses.
There are thirteen domains for...
Nursing Diagnosis01:22

Nursing Diagnosis

Following assessment, a nursing diagnosis is the next step in the nursing process. It begins after the nurse has collected and recorded the patient data. The purpose of diagnosing is to identify how the client responds to actual or potential health processes, identify factors that bestow or that cause health problems, the etiologies, and identify resources or strengths the individual, group, or community can draw on to prevent or resolve problems.
The nursing diagnosis focuses on evidence-based...
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:

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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

Enhancing clinical problem lists through data mining and natural language processing.

Elizabeth S Chen1, Adam Wright, Francine L Maloney

  • 1Clinical Informatics Research & Development, Partners HealthCare System, Wellesley, MA, USA.

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

Accurate clinical problem lists are vital for healthcare. This study explores automated methods to improve outdated and incomplete problem lists, enhancing patient care quality.

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Area of Science:

  • Health Informatics
  • Clinical Decision Support
  • Medical Record Management

Background:

  • Timely, accurate, and comprehensive clinical problem lists are crucial for healthcare operations.
  • Existing problem lists often suffer from being outdated, incomplete, or containing uncoded entries.
  • These deficiencies can impede effective patient care and healthcare system efficiency.

Purpose of the Study:

  • To investigate automated techniques for enhancing the quality of clinical problem lists.
  • To address the common issues of outdatedness, omissions, and uncoded entries in problem lists.
  • To explore methods for improving the reliability and utility of electronic health record problem lists.

Main Methods:

  • A study was conducted at Partners HealthCare System.
  • Exploration of automated techniques for problem list enhancement.
  • Focus on improving accuracy, timeliness, and completeness of problem data.

Main Results:

  • The study is exploring automated techniques.
  • Initial findings are focused on the feasibility of enhancing problem lists.
  • The research aims to provide a foundation for improved problem list management.

Conclusions:

  • Automated techniques hold promise for improving clinical problem lists.
  • Enhancing problem lists can support better healthcare activities.
  • Further research is needed to implement and validate these automated methods.