Jove
Visualize
Contact Us
JoVE
x logofacebook logolinkedin logoyoutube logo
ABOUT JoVE
OverviewLeadershipBlogJoVE Help Center
AUTHORS
Publishing ProcessEditorial BoardScope & PoliciesPeer ReviewFAQSubmit
LIBRARIANS
TestimonialsSubscriptionsAccessResourcesLibrary Advisory BoardFAQ
RESEARCH
JoVE JournalMethods CollectionsJoVE Encyclopedia of ExperimentsArchive
EDUCATION
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab ManualFaculty Resource CenterFaculty Site
Terms & Conditions of Use
Privacy Policy
Policies

Related Concept Videos

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...
Guidelines and Strategies for Safe Computer Charting01:18

Guidelines and Strategies for Safe Computer Charting

The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Legal Guidelines for Documentation01:06

Legal Guidelines for Documentation

The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:  
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by
Same author

Key CPT and Medicare Changes for Family Medicine in 2022.

Family practice management·2022
Same author

The Quest for Administrative Simplification: What's Being Done.

Family practice management·2021
Same author

The 2021 Medicare Payment and CPT Coding Update.

Family practice management·2021
Same author

The 2021 Office Visit Coding Changes: Putting the Pieces Together.

Family practice management·2020
Same author

The 2020 Medicare Documentation, Coding, and Payment Update.

Family practice management·2020
Same author

The 2019 Medicare Documentation, Coding, and Payment Update.

Family practice management·2019
Same journal

Reclaiming the Clinical Story: Ambient AI and the Future of Documentation.

Family practice management·2026
Same journal

How to Keep the Chart From Becoming the Plaintiff's Best Witness.

Family practice management·2026
Same journal

Tattoos, Core Memories, and Helping Patients Change.

Family practice management·2026
Same journal

A Guide to Implementing Fourth-Trimester Care in a Family Medicine Practice.

Family practice management·2026
Same journal

11 Tips for More Effective AI Clinical Searches.

Family practice management·2026
Same journal

Practical Tips for Addressing Patient Loneliness in Primary Care.

Family practice management·2026
See all related articles

Related Experiment Video

Updated: Jun 13, 2026

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies
10:38

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Published on: January 16, 2019

Exam documentation: charting within the guidelines

Kent J Moore1

  • 1AAFP, USA.

Family Practice Management
|May 15, 2010
PubMed
Summary

No abstract available in PubMed .

Related Experiment Videos

Last Updated: Jun 13, 2026

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies
10:38

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Published on: January 16, 2019