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Related Concept Videos

Methods of Documentation I: Source-Oriented Records01:18

Methods 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:
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...
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...
Classification of Illness01:17

Classification of Illness

The meaning of illness is individualized to each person who experiences an alteration in health. In contrast, disease is a medical term indicating a pathological change in the structure and function of the body or mind. It is a condition that has specific symptoms and boundaries.
An illness is a response to a disease in which the person's level of functioning is changed compared with a previous level. The general classification of illness includes acute and chronic.
Acute illness is severe and...
Methods of Documentation II: POMR01:26

Methods of Documentation II: POMR

The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
Types of Records I: Unit and Nurses Records01:27

Types of Records I: Unit and Nurses Records

Unit records in healthcare settings document the patient's treatment history, including interventions, medications, diagnostic and laboratory results, progress notes, personal care needs, vital signs, and other medical information. They are crucial for managing patient care, aiding healthcare professionals in providing quality treatment and informed decision-making.
Unit records can be divided into two main types: administrative records and clinical records.
Administrative records in...

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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
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Recording associated disorders using SNOMED CT.

Ronald Cornet1, Nicolette F de Keizer

  • 1Department of Medical Informatics, Academic Medical Center, University of Amsterdam, The Netherlands.

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

Accurate electronic medical records require proper modeling of associated patient disorders using SNOMED CT. Incomplete disorder associations in SNOMED CT hinder data reuse, necessitating improved terminology integration.

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Area of Science:

  • Medical Informatics
  • Health Informatics
  • Clinical Terminology

Background:

  • Effective multidisciplinary communication is crucial for high-quality patient care, especially for patients with multiple interrelated diseases.
  • Electronic medical records (EMRs) are central to healthcare communication and data management.
  • Standardized terminologies like SNOMED CT are essential for consistent data representation.

Purpose of the Study:

  • To design and discuss methods for appropriately recording associations between disorders in EMRs using SNOMED CT.
  • To analyze the use and implications of the "associated with" relationship in SNOMED CT for data reuse.
  • To identify challenges in representing disorder associations for improved data interoperability.

Main Methods:

  • Analysis of SNOMED CT's "associated with" relationship for disorder associations.
  • Evaluation of current practices for recording patient disorders and their interrelations in EMRs.
  • Exploration of alternative methods for representing concept characteristics within EMRs.

Main Results:

  • The current modeling of disorder associations in SNOMED CT is often incorrect or incomplete.
  • This incomplete modeling significantly hampers the reproducible recording of reusable data in EMRs.
  • Existing use of the "associated with" relationship in SNOMED CT has negative consequences for data reuse.

Conclusions:

  • Improved modeling of disorder associations within SNOMED CT is necessary for robust EMR data.
  • Recording concept characteristics directly in EMRs, rather than relying solely on terminology, may offer a solution.
  • Further research is required to effectively bind information models with terminologies for better data integration.