Related Concept Videos
01:30Methods 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,...
01:18Methods of Documentation I: Source-Oriented Records
Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
01:27Nursing 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.
Critical attributes of NCIS include:
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.
Critical attributes of NCIS include:
01:28Formats for Nursing Documentation
Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
01:18Guidelines 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:
Maintain Confidentiality and Security:
01:06Legal 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:
You might also read
Related Articles
Articles linked to this work by shared authors, journal, and citation graph.
Sort by
Same author
Initiation of an emergency department discharge pathway for low-risk patients with venous thromboembolism: Factors impact real-world practice.
Vascular medicine (London, England)·2026
Same author
Systematic common and rare variant association testing in 392,030 whole genomes in <i>All of Us</i>.
medRxiv : the preprint server for health sciences·2026
Same author
Multi-scale data improves performance of machine learning model for long COVID identification.
Communications medicine·2026
Related Experiment Video
Updated: Jun 7, 2026
07:50
A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
Generating Clinical Notes for Electronic Health Record Systems.
S Trent Rosenbloom1, William W Stead, Joshua C Denny
1Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN.
Applied Clinical Informatics
|October 30, 2010
Summary
Implementing electronic health record (EHR) systems requires careful consideration of clinical documentation methods. Vanderbilt
Area of Science:
- Health Informatics
- Clinical Documentation Improvement
- Electronic Health Records
Background:
- Clinical notes are vital for patient-provider interactions.
- Structured clinical notes are increasingly emphasized for data reuse in electronic health record (EHR) systems.
- Clinical documentation presents significant challenges in EHR system development and adoption.
Purpose of the Study:
- To describe Vanderbilt's experience implementing clinical documentation within an EHR system.
- To provide recommendations for selecting clinical documentation methods in EHRs.
Main Methods:
- The study details the rollout of an EHR system at Vanderbilt.
- The EHR system supported multiple clinical documentation methods.
- Analysis focused on the practical implementation and outcomes.
Main Results:
- Selecting documentation methods should prioritize clinical workflow, note content standards, and usability.
- A theoretical need for structured data alone is insufficient for method selection.
- Vanderbilt's experience highlights practical considerations over theoretical ones.
Conclusions:
- Clinical documentation method selection in EHRs should be guided by practical workflow and usability factors.
- Focusing on clinical workflow and usability enhances EHR adoption and effectiveness.
- Recommendations are based on real-world implementation experiences at Vanderbilt.