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Related Concept Videos

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...
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,...
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 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.
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:
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.

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Related Experiment Video

Updated: May 26, 2026

A Computer-Based Platform for Aiding Clinicians in Eating Disorder Analysis and Diagnosis
04:19

A Computer-Based Platform for Aiding Clinicians in Eating Disorder Analysis and Diagnosis

Published on: May 10, 2022

Coding of procedures documented by general practitioners in Swedish primary care-an explorative study using two

Anna Vikström1, Maria Hägglund, Mikael Nyström

  • 1Department of Neurobiology, Care Sciences and Society, Center for Family and Community Medicine, Karolinska Institutet, SE-141 83 Huddinge, Sweden. anna.vikstrom@sll.se

BMC Family Practice
|January 11, 2012
PubMed
Summary

General practitioners document many procedures in electronic records. SNOMED CT effectively codes these procedures, unlike the Swedish Classification of Health Interventions (KVÅ), which offers less coverage and concordance.

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Last Updated: May 26, 2026

A Computer-Based Platform for Aiding Clinicians in Eating Disorder Analysis and Diagnosis
04:19

A Computer-Based Platform for Aiding Clinicians in Eating Disorder Analysis and Diagnosis

Published on: May 10, 2022

Area of Science:

  • Primary care research
  • Health informatics
  • Medical coding systems

Background:

  • Procedures documented by general practitioners (GPs) in primary care are understudied concerning coding systems.
  • Electronic patient records (EPRs) are increasingly used in primary care settings.

Purpose of the Study:

  • To describe procedures documented by Swedish GPs in EPRs.
  • To compare the coding of these procedures using the Swedish Classification of Health Interventions (KVÅ) and SNOMED CT.

Main Methods:

  • Identification and coding of procedures from 200 GP EPR entries.
  • Assessment of coded procedures against KVÅ and SNOMED CT.
  • Analysis of coding concordance and coverage.

Main Results:

  • 417 procedures were identified and coded using 36 KVÅ categories and 148 SNOMED CT concepts.
  • 22.8% of procedures could not be coded with KVÅ, versus 4.3% with SNOMED CT.
  • SNOMED CT demonstrated higher concordance (206 matches) compared to KVÅ (10 matches).

Conclusions:

  • Procedures are frequently documented in GP EPRs.
  • SNOMED CT is a comprehensive and flexible system for coding primary care procedures.
  • KVÅ has limited coverage and concordance for GP-documented procedures.