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Related Concept Videos

Methods of Documentation VII: EMR01:30

Methods 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,...
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Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
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Here's a breakdown of how health records serve these purposes:
Health Literacy01:21

Health Literacy

Health literacy is an individual's or a community's capacity to comprehend, receive, read, and use relevant healthcare information and services. The World Health Organization (WHO, 2018) defines health literacy as the cognitive and social skills that determine the ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. As a result, the WHO helps individuals manage long-term health concerns, participate in preventative programs,...
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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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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
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Evaluation of a Hyperlinked Consumer Health Dictionary for reading EHR notes.

Laura Slaughter1, Karl Oyri, Erik Fosse

  • 1The Intervention Centre, Oslo University Hospital and Dept. of Clinical Medicine, Oslo, Norway.

Studies in Health Technology and Informatics
|September 7, 2011
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Summary

This study tested a consumer health dictionary embedded in electronic health records (EHR). Patients found detailed definitions helpful but preferred avoiding unfamiliar terms for better understanding of their health information.

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Area of Science:

  • Health Informatics
  • Consumer Health Information
  • Patient Education

Background:

  • Electronic Health Records (EHR) can be complex for patients.
  • Access to understandable health information is crucial for patient engagement.
  • A Consumer Health Dictionary (IVS-CHD) was developed to aid patient comprehension.

Purpose of the Study:

  • To pilot test the usefulness and understandability of the IVS-CHD.
  • To evaluate the dictionary's functionality within EHR systems.
  • To inform the methodology for iterative development of the IVS-CHD.

Main Methods:

  • A hyperlinked IVS-CHD was integrated into EHRs for thoracic surgery patients.
  • Patients rated definition usefulness and understandability using Likert scales.
  • Undefined terms requested by patients were recorded.

Main Results:

  • Patients prefer detailed definitions including medical outcomes.
  • Definitions should avoid jargon or terms requiring further lookup.
  • Patients requested definitions for specific abbreviations and terms found in EHR notes.

Conclusions:

  • Embedded health dictionaries can improve patient understanding of EHRs.
  • Definition content and clarity are critical for patient comprehension.
  • Iterative development based on patient feedback is essential for effective health dictionaries.