Related Experiment Video
Updated: May 28, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
Source of truth: where is it in your documentation?
Catherine Whelchel1, Ruth Nordquist, Dianne Koepping
1McKesson Provider Technologies, Westminster, CO, USA.
Abstract:
In summary, a variety of documentation sources may affect reporting accuracy as well as bedside efficiency. the successful process to streamline documentation at HealthEast requires clinicians from the bedside, informatics staff, and the quality office to ensure an efficient and thoughtful implementation. As hospitals begin to address the HITECH guidelines for electronic reporting, current documentation infrastructure may provide opportunity for process improvement. Where is your source of truth?
Related Concept Videos
Methods of Documentation I: Source-Oriented Records
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:
Legal Guidelines for Documentation
Methods of Documentation V: CBE
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
Methods of Documentation IV: Focus Charting
It typically involves three columns for recording information:
Introduction to Documentation and Reporting
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...
Methods of Documentation III: PIE