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Related Concept Videos

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
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 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:
Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation01:20

Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation

Evaluation of the teaching process enables the nurse to determine if the patient's learning needs were met and if training was effective. If the expected outcomes are not met, the care plan is revised, and additional education or reinforcement is provided. Nurses can ask questions after the session or obtain feedback to assess the patient's understanding of the topic.
Nurses can use several methods to evaluate patient outcomes. For example, oral questions can assess cognitive learning, patient...
Documentation of Nursing Diagnosis01:10

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.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
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...

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Related Experiment Video

Updated: May 29, 2026

E-Patient Counseling Trial (E-PACO): Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy
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E-Patient Counseling Trial (E-PACO): Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

Published on: August 1, 2019

Technical data evaluation of a palliative care web-based documentation system.

Tobias Hartz1, René Brüntrup, Frank Uckert

  • 1Institute of Medical Informatics, University Hospital Münster, Germany. hartz@imfl.de

Studies in Health Technology and Informatics
|September 7, 2011
PubMed
Summary
This summary is machine-generated.

A technical analysis of the eKernPäP patient documentation system revealed usage patterns and data generation. Findings indicate areas for improvement in form completion and navigation, enhancing web-based healthcare documentation.

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Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform
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Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform

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Last Updated: May 29, 2026

E-Patient Counseling Trial (E-PACO): Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy
06:28

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Published on: August 1, 2019

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07:13

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Published on: April 12, 2021

Area of Science:

  • Health Informatics
  • Palliative Care Technology

Background:

  • Web-based documentation systems are crucial for interdisciplinary pediatric palliative care teams.
  • Efficient documentation supports outpatient care coordination and quality.

Purpose of the Study:

  • To conduct a technical analysis of the eKernPäP system used in German pediatric palliative care.
  • To evaluate system usage, data generation, and user navigation patterns.

Main Methods:

  • Analysis of system data from eKernPäP.
  • Evaluation of data from an external web analytic system.
  • Detailed review of individual documentation forms and user navigation paths.

Main Results:

  • The analysis provided an overview of system utilization and information output.
  • Incomplete form completion was identified as an issue.
  • User navigation predominantly followed the designed pathways, with one exception identified for correction.

Conclusions:

  • Technical analysis is an effective method for improving web-based documentation systems.
  • eKernPäP usage data and navigation patterns offer insights for system enhancement.
  • Addressing form completion and navigation anomalies will optimize the system's utility.