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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 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.
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Standards of Care I

Federal statutes profoundly impact nursing practice, providing critical guidelines to ensure patient care is equitable, accessible, and of the highest quality. The following laws address distinct aspects of healthcare provision and patient rights:
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Nursing Implementation

Implementation is the execution of the nursing care plan developed during the planning phase.
The five steps to implementing effective nursing care include reassessing the patient, reviewing and revising the existing nursing care plan, organizing the resources and care delivery, anticipating and preventing complications, and implementing nursing interventions.
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:

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Ten steps to EMR assimilation into a practice.

Debra McGrath1

  • 1Coker Group, 7 Bala Avenue, Suite 303, Bala Cynwyd, PA 19004, USA. dmcgrath@cokergroup.com

The Journal of Medical Practice Management : MPM
|May 22, 2009
PubMed
Summary

Physicians can prepare for electronic health record (EHR) implementation by understanding the transition process. This guide offers practical tools for a smoother shift from paper to digital patient records.

Area of Science:

  • Health Informatics
  • Medical Practice Management

Background:

  • Physician adoption of computerized patient records presents significant challenges.
  • Anecdotal evidence highlights difficulties during the assimilation of electronic health records (EHRs).

Purpose of the Study:

  • To provide physicians with practical strategies for preparing for EHR implementation.
  • To demystify the transition process from paper-based to electronic patient record systems.

Main Methods:

  • Review of common challenges associated with EHR adoption.
  • Development of a practical toolkit for physician preparedness.

Main Results:

  • Understanding expected challenges facilitates smoother EHR implementation.
  • Proactive preparation is key to successful transition from paper to electronic records.

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Conclusions:

  • Physicians require practical guidance to navigate EHR implementation effectively.
  • Preparation and expectation management are crucial for successful adoption of digital health records.