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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
Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...
Legal Guidelines for Documentation01:06

Legal Guidelines for Documentation

The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
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:
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:  
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.

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Related Experiment Video

Updated: May 28, 2026

Using a Real-Time Locating System to Measure Walking Activity Associated with Wandering Behaviors Among Institutionalized Older Adults
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Using a Real-Time Locating System to Measure Walking Activity Associated with Wandering Behaviors Among Institutionalized Older Adults

Published on: February 8, 2019

An automated procedure logging system improves resident documentation compliance.

Thomas S Seufert1, Patricia M Mitchell, Allison R Wilcox

  • 1Department of Emergency Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA. jeffrey.schneider@bmc.org

Academic Emergency Medicine : Official Journal of the Society for Academic Emergency Medicine
|October 18, 2011
PubMed
Summary
This summary is machine-generated.

An automated procedure logging (APL) system significantly increased the number of procedures logged by emergency medicine residents. This system also improved the completeness and accuracy of logged data, enhancing resident competency assessment.

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Improving IV Insulin Administration in a Community Hospital
12:08

Improving IV Insulin Administration in a Community Hospital

Published on: June 11, 2012

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Last Updated: May 28, 2026

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04:13

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Published on: February 8, 2019

Improving IV Insulin Administration in a Community Hospital
12:08

Improving IV Insulin Administration in a Community Hospital

Published on: June 11, 2012

Area of Science:

  • Medical Education
  • Health Informatics
  • Emergency Medicine

Background:

  • Accurate procedure logging is crucial for resident education and competency assessment in Emergency Medicine (EM).
  • Manual logging methods are often incomplete and inaccurate, posing challenges for evaluating resident performance.
  • Existing systems may not efficiently capture all procedures performed by residents.

Purpose of the Study:

  • To evaluate the impact of an automated procedure logging (APL) system on the quantity of procedures logged by EM residents.
  • To assess changes in the completeness and accuracy of procedure logging after APL implementation.
  • To measure resident compliance with the new APL system.

Main Methods:

  • A before-and-after study design was employed at a large urban academic medical center.
  • An APL system was developed to extract procedure data from the electronic medical record (EMR).
  • Mean daily procedure logs were compared pre- and post-APL implementation using a two-sample t-test; completeness and accuracy were assessed via random sampling and Fisher's exact test.

Main Results:

  • The mean daily number of logged procedures increased by 168% post-APL (10.0 to 26.8, p < 0.001).
  • APL-logged procedures demonstrated significantly higher completeness (76% vs. 100%, p < 0.001) and accuracy (87% vs. 99%, p < 0.001).
  • Resident compliance was high, with 88% using APL for at least 90% of procedures, and only 4% of eligible procedures logged manually post-APL.

Conclusions:

  • Implementation of the APL system led to a substantial increase in the number of procedures logged by EM residents.
  • The APL system significantly improved the completeness and accuracy of procedure documentation.
  • This innovative APL system enhances the assessment of resident competencies, including Patient Care and Practice-Based Learning, as defined by the ACGME.