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Related Concept Videos

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:
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...
Data Validation01:15

Data Validation

Method validation is a crucial process in analytical chemistry designed to confirm that a given method consistently produces reliable and high-quality results. This process is essential when a method is applied to different sample matrices or when procedural modifications are made, ensuring that the results meet acceptable standards across various applications.
Key parameters for method validation include:
Data Collection II01:29

Data Collection II

The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and family,...
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:
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...

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Databases to Efficiently Manage Medium Sized, Low Velocity, Multidimensional Data in Tissue Engineering
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Databases to Efficiently Manage Medium Sized, Low Velocity, Multidimensional Data in Tissue Engineering

Published on: November 22, 2019

A development of conceptual framework for structured data entry in procedure.

Misook Kwak1, Yookyung Boo, Sunju Ahn

  • 1Center for Interoperable EHR, Korea.

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

This study introduces a structured data framework for clinical procedures, enhancing point-of-care data entry. It utilizes ISO standards and the Entity-Attribute-Value model for organized clinical content and disease record data.

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Area of Science:

  • Medical Informatics
  • Health Data Standards

Background:

  • Clinical data entry at the point of care often lacks structure.
  • Standardized frameworks are needed for efficient and accurate clinical content management.

Purpose of the Study:

  • To develop a conceptual framework for clinical contents in procedures.
  • To enable clinicians with structured data entry capabilities at the point of care.

Main Methods:

  • Applied the International Organization for Standardization's (ISO) conceptual framework for clinical content modeling.
  • Employed semantic structuring and the Entity-Attribute-Value (EAV) model for data representation.
  • Developed a conceptual framework for procedures with twenty-one attributes.

Main Results:

  • A conceptual framework for clinical procedures was successfully developed.
  • Structured clinical data sets for operation records were created, covering six diseases.
  • The framework facilitates structured data entry for clinicians.

Conclusions:

  • The proposed conceptual framework enhances the structure of clinical content in procedures.
  • This framework supports standardized data entry and management for clinical operations and disease records.