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Related Concept Videos

Nursing Clinical Information System01:27

Nursing 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.
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Methods of Documentation III: PIE01:21

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:
Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic illness...
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...
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:
Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities

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Related Experiment Video

Updated: May 30, 2026

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
08:13

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

Published on: January 20, 2019

Implementation of a school-wide clinical intervention documentation system.

T Lynn Stevenson1, Brent I Fox, Miranda Andrus

  • 1Auburn University Harrison School of Pharmacy, AL, USA. tls0002@auburn.edu

American Journal of Pharmaceutical Education
|August 11, 2011
PubMed
Summary

A web-based software program effectively documented clinical interventions by pharmacy trainees and faculty. This system demonstrated significant cost avoidance, highlighting the value of systematic data collection in pharmacy practice.

Keywords:
assessmentclinical interventiondocumentationimplementationtechnology

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Area of Science:

  • Pharmacy Education
  • Health Informatics
  • Clinical Practice Management

Background:

  • Pharmacy practice faculty, residents, and student pharmacists engage in numerous clinical interventions.
  • Systematic documentation of these interventions is crucial for demonstrating value and impact.
  • A customized Web-based software program was developed to facilitate this documentation.

Purpose of the Study:

  • To assess the effectiveness and impact of a Web-based software program for documenting clinical interventions.
  • To evaluate the implementation of this tool across a school of pharmacy.

Main Methods:

  • A committee oversaw software refinement, user training, form development, and curriculum integration.
  • The implementation process spanned from 2006 onwards.
  • Data collection practices were continuously monitored.

Main Results:

  • Consistent increase in the use of the documentation tool from May 2007 to December 2010.
  • Over 187,000 clinical interventions were documented.
  • Associated cost avoidance exceeded $6.2 million.

Conclusions:

  • Successful implementation required significant committee effort and comprehensive user training.
  • Ongoing monitoring of data collection is essential for sustained success.
  • The collected data effectively demonstrated the impact of pharmacy personnel at training sites.