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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,...
Data Reporting and Recording01:24

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
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:
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...
Health Information Technology and Healthcare Information System01:30

Health Information Technology and Healthcare Information System

Health Information Technology (HIT)
Health Information Technology, commonly called HIT, integrates advanced information systems and technology in healthcare settings. Its primary functions include:
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...

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Related Experiment Video

Updated: May 29, 2026

Executing Complexity-Increasing Queries in Relational (MySQL) and NoSQL (MongoDB and EXist) Size-Growing ISO/EN 13606 Standardized EHR Databases
07:26

Executing Complexity-Increasing Queries in Relational (MySQL) and NoSQL (MongoDB and EXist) Size-Growing ISO/EN 13606 Standardized EHR Databases

Published on: March 19, 2018

Representing knowledge, data and concepts for EHRS using DCM.

William Goossen1

  • 1Health Care Windesheim, Zwolle, The Netherlands. wgoossen@results4care.nl

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

Detailed Clinical Modeling (DCM) offers a solution for organizing clinical knowledge in next-generation Electronic Health Record Systems (EHRS). This approach enables semantic data exchange, overcoming challenges in current healthcare IT and supporting the

Related Experiment Videos

Last Updated: May 29, 2026

Executing Complexity-Increasing Queries in Relational (MySQL) and NoSQL (MongoDB and EXist) Size-Growing ISO/EN 13606 Standardized EHR Databases
07:26

Executing Complexity-Increasing Queries in Relational (MySQL) and NoSQL (MongoDB and EXist) Size-Growing ISO/EN 13606 Standardized EHR Databases

Published on: March 19, 2018

Area of Science:

  • Health Informatics
  • Clinical Knowledge Representation
  • Information Modeling

Background:

  • Next-generation Electronic Health Record Systems (EHRS) are shifting focus from administrative tasks to clinical functions.
  • Integrating clinical knowledge and evidence bases into EHRS presents significant challenges.
  • Clinicians desire EHRS support without sacrificing care standardization, seeking unified terminology and structured data alongside free text.

Purpose of the Study:

  • To advocate for Detailed Clinical Modeling (DCM) as a method for organizing clinical knowledge in EHRS.
  • To address the complexities arising from diverging approaches in healthcare IT and EHRS information modeling.
  • To enable semantic data exchange independent of specific technologies.

Main Methods:

  • Proposes Detailed Clinical Modeling (DCM) as a strategic approach.
  • Focuses on organizing clinical knowledge and defining data structures.
  • Emphasizes the exchange of semantic information.

Main Results:

  • DCM facilitates the organization of clinical knowledge for EHRS.
  • It enables semantic interoperability, allowing data to be understood across different systems.
  • DCM supports the 'enter data once, reuse multiple times' paradigm.

Conclusions:

  • A shift towards Detailed Clinical Modeling is necessary for advancing EHRS capabilities.
  • DCM provides a robust framework for representing clinical concepts and data.
  • This method enhances the utility of EHRS by ensuring flexible and reusable clinical information.