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Data Reporting and Recording

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...

Methods of Documentation III: PIE

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:

Types of Biopharmaceutical Studies: Controlled and Non-Controlled Approaches

Types of Biopharmaceutical Studies: Controlled and Non-Controlled Approaches

Biopharmaceutical studies constitute a vital field aiming to enhance drug delivery methods and refine therapeutic approaches, drawing upon diverse interdisciplinary knowledge. In research methodologies, the choice between controlled and non-controlled studies significantly influences the study's reliability and accuracy.
Non-controlled studies, commonly employed for initial exploration, lack a control group, rendering them susceptible to biases and external influences. In contrast, controlled...

Methods of Documentation II: POMR

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.

Documentation of Nursing Diagnosis

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...

Data Collection I

Data Collection I

Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, subjective data is collected from the patient, their caregivers, or family members, and objective data is collected through observations and physical assessment. Patients are the primary source of subjective data. Thus information gathered from patients through interviews, observations, and physical examination is primary data. Secondary sources of data...

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Related Experiment Video

Updated: Jun 19, 2026

Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index

Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index

Published on: January 8, 2020

Methodological issues affecting the value of patient-reported outcomes data.

Michael R Hufford¹, Saul Shiffman

¹Scientific Affairs, Invivodata, Inc., 2100 Wharton St., Ste. 505, Pittsburgh, PA 15203, USA. mhufford@invivodata.com

Expert Review of Pharmacoeconomics & Outcomes Research

|October 8, 2009

Summary

Collecting patient-reported outcomes data requires careful methodology. Ecological momentary assessment offers a promising approach to improve the validity and value of this crucial health information.

Related Experiment Videos

Last Updated: Jun 19, 2026

Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index

Inverse Probability of Treatment Weighting (Propensity Score) using the Military Health System Data Repository and National Death Index

Published on: January 8, 2020

Area of Science:

Health Services Research
Clinical Epidemiology
Patient-Reported Outcomes

Background:

Patient-reported outcomes (PROs) data are vital for understanding patient experiences.
The reliability and validity of PROs depend significantly on data collection methods.
Methodological challenges can impact the accurate reflection of patients' daily lives.

Purpose of the Study:

To review the impact of methodological issues on the value of PRO data.
To explore strategies for enhancing the quality of PRO data.
To highlight promising methods for real-time data collection.

Main Methods:

Literature review examining methodological factors in PRO data collection.
Analysis of challenges in self-monitoring of experiences, disease episodes, and healthcare utilization.
Evaluation of ecological momentary assessment as a data collection technique.

Main Results:

Various methodological issues can compromise the validity of PRO data.
Self-monitoring requires careful consideration of data collection techniques.
Ecological momentary assessment shows potential for improving PRO data quality.

Conclusions:

Addressing methodological issues is crucial for reliable PRO data.
Ecological momentary assessment can enhance the value of PRO data by capturing real-time patient experiences.
Improved data collection methods lead to a more accurate understanding of patient health.