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Related Concept Videos

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.
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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...
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 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.
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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.
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Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

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Related Experiment Video

Updated: Jun 21, 2026

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
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Published on: January 20, 2019

A study of best practices for clinical documentation system implementation.

Susan K Newbold1, Kathleen Kimmel, Randy Osteen

  • 1Vanderbilt School of Nursing, Nashville, TN, USA. susan.newbold@vanderbilt.edu

Studies in Health Technology and Informatics
|July 14, 2009
PubMed
Summary

Nurses are vital for implementing clinical documentation systems. Strong leadership support, especially from nursing executives, is crucial for success and improving patient safety.

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Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
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The Participant-Reported Implementation Update and Score (PRIUS): A Novel Method for Capturing Implementation-Related Data Over Time
06:05

The Participant-Reported Implementation Update and Score (PRIUS): A Novel Method for Capturing Implementation-Related Data Over Time

Published on: February 19, 2021

Area of Science:

  • Healthcare Informatics
  • Nursing Leadership
  • Clinical Systems Implementation

Background:

  • Nurses play a critical role in the adoption of clinical documentation systems.
  • Traditional barriers often hinder the successful implementation of these systems.
  • Effective technology integration is essential for patient safety and quality improvement.

Purpose of the Study:

  • To review key success factors for implementing clinical documentation systems.
  • To identify strategies for overcoming implementation barriers.
  • To emphasize the role of technology in enhancing patient safety and quality improvement.

Main Methods:

  • Literature review of clinical documentation system implementation.
  • Analysis of success factors and barriers.
  • Focus on nursing leadership and management support.

Main Results:

  • Top-level management support, particularly from nursing executives, is a vital success factor.
  • Overcoming traditional barriers requires commitment to universal goals.
  • Facilitating technology use is key for patient safety.

Conclusions:

  • Nursing leadership is paramount for successful clinical documentation system implementation.
  • Sustained management commitment ensures alignment with patient safety and quality goals.
  • Effective implementation leverages technology for continuous healthcare improvement.