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Related Concept Videos

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 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...
Nursing Clinical Information System01:27

Nursing Clinical Information System

Nursing Clinical Information System (NCIS)
A Nursing Clinical Information System (NCIS) is a specialized type of healthcare information system tailored to meet the unique needs of nursing practice. It incorporates the principles of nursing informatics to streamline information management and improve the quality of care delivery.
Critical attributes of NCIS include:
Formats for Nursing Documentation01:28

Formats for Nursing Documentation

Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history, current medications, vital...
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 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:

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Related Experiment Video

Updated: May 19, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
07:50

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

Ontology-based reusable clinical document template production system.

Sejin Nam1, Sungin Lee, James G Boram Kim

  • 1Seoul National University, Seoul, Korea.

Studies in Health Technology and Informatics
|August 10, 2012
PubMed
Summary
This summary is machine-generated.

This study introduces an effective clinical document template (CDT) production system. It leverages a clinical description entity (CDE) model, ontology, and knowledge management system for improved clinical documentation.

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Area of Science:

  • Medical Informatics
  • Knowledge Representation
  • Clinical Documentation

Background:

  • Clinical documents are crucial for professional knowledge transfer.
  • Existing methods for clinical document template (CDT) production can be inefficient.
  • Standardization and effective management of clinical information are needed.

Purpose of the Study:

  • To present an effective clinical document template (CDT) production system.
  • To demonstrate the integration of a clinical description entity (CDE) model and ontology.
  • To showcase a knowledge management system (STEP) for managing CDEs and CDTs.

Main Methods:

  • Developed a system utilizing a CDE model and CDE ontology.
  • Implemented the STEP knowledge management system to manage ontology-based CDEs.
  • Integrated Web Services for searching and reasoning over clinical entities.
  • Extracted entities and relations from 35 diverse clinical documents.

Main Results:

  • The system effectively produces clinical document templates (CDTs).
  • The STEP system successfully manages ontology-based clinical description entities (CDEs).
  • Web Services enable efficient search and reasoning capabilities over clinical data.
  • The system was populated with data from various clinical reports.

Conclusions:

  • The presented system offers an effective approach to clinical document template production.
  • Ontology-based knowledge management enhances the organization and retrieval of clinical information.
  • The system facilitates improved clinical documentation and knowledge sharing.