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Methods of Documentation V: CBE

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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Related Experiment Video

Updated: Jun 8, 2026

Introduction of an Integrated Pathology Image Management, Artificial Intelligence, and Reporting System

Introduction of an Integrated Pathology Image Management, Artificial Intelligence, and Reporting System

Published on: July 11, 2025

HL7 CDA implementation guide for structured anatomic pathology reports methodology and tools.

Haitham Kussaibi¹, François Macary, Mary Kennedy

¹INSERM, UMR_S 872, Eq. 20, Paris, F-75006 France. h.kussaibi@gmail.com

Studies in Health Technology and Informatics

|September 16, 2010

Summary

This summary is machine-generated.

Developing an international standard for anatomic pathology reports (APRs) is now possible. This enables better data exchange for cancer pathology reports, improving patient care and research globally.

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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

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Introduction of an Integrated Pathology Image Management, Artificial Intelligence, and Reporting System

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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

Area of Science:

Medical Informatics
Health Information Exchange
Pathology Reporting Standards

Background:

Anatomic pathology reports (APRs) are vital for patient care, research, and epidemiology.
Current limitations in international data exchange hinder collaborative efforts.
Standardization is needed for seamless APR data interoperability.

Purpose of the Study:

To establish an international methodology and tools for creating HL7 Clinical Document Architecture (CDA) implementation guides for APRs.
To focus specifically on standardizing cancer pathology reports for global use.

Main Methods:

A four-step methodology was used, involving comparative analysis of international APR models.
Consensus-based clinical models were derived using the Delphi technique.
HL7 CDA implementation guides (CDA templates) were developed and validated.

Main Results:

International experts successfully defined HL7 CDA implementation guides for breast and colon cancer APRs.
The developed CDA templates specify required and optional data elements, allowing for national extensions.
This establishes a foundation for a unified international standard in cancer pathology reporting.

Conclusions:

An international HL7 CDA implementation guide for cancer APRs is feasible.
Further development is required for approximately 60 other cancer types and non-neoplastic pathologies.
The methodology is adaptable for standardizing various clinical document types beyond APRs.