Related Concept Videos
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:
01:30Guidelines 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.
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
01:23Methods 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...
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
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:
01:18Guidelines 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:
01:30Methods 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,...
You might also read
Related Articles
Articles linked to this work by shared authors, journal, and citation graph.
Sort by
Same journal
Inequity Is Our Biggest Killer: Looking Upstream to Tackle the Burden of Disease in Australia.
The Medical journal of Australia·2026
Same journal
Australian Pathways for Specialist Pain Management and Early Palliative Care for People With Pancreatic Cancer: Developed Using a Community Consensus Approach.
The Medical journal of Australia·2026
Related Experiment Video
Updated: Jun 5, 2026
04:41
Knee Arthrocentesis in Adults
Published on: February 25, 2022
Doctors writing outside the square.
1tyhurley@optusnet.com.au
The Medical Journal of Australia
|January 19, 2011
Summary
Doctors often write engaging non-medical publications. This study explores works by three Victorian doctors, examining their motivations and the lasting appeal of their writings outside of medicine.
Area of Science:
- Medical Humanities
- History of Medicine
- Literature and Medicine
Background:
- Explores publications by physicians on non-professional topics.
- Highlights the work of Dr. Graeme Robertson, Sir Clive Fitts, and Professor Richard Lovell from Victoria.
- Focuses on their skillful and artistic writing outside of their medical expertise.
Discussion:
- Analyzes the motivations behind these doctors' non-technical writing endeavors.
- Examines the literary qualities and artistic merit of their diverse publications.
- Considers the intersection of medical expertise and broader intellectual pursuits.
Key Insights:
- Physicians' non-technical writings can achieve significant readership and longevity.
- Skillful artistry contributes to the enduring interest in these works.
Outlook:
- Suggests potential for further research into physician authors and their broader contributions.
- Encourages exploration of the medical humanities and the impact of doctors' non-professional writings.
- Highlights the value of interdisciplinary perspectives in understanding scholarly and artistic output.