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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 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 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...
Guidelines and Strategies for Safe Computer Charting01:18

Guidelines and Strategies for Safe Computer Charting

The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
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:
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...

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Related Experiment Video

Updated: May 13, 2026

Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide
09:52

Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

Published on: January 15, 2017

Work-practice changes associated with an electronic emergency department whiteboard.

Morten Hertzum1, Jesper Simonsen

  • 1Roskilde University, Denmark. mhz@ruc.dk

Health Informatics Journal
|March 15, 2013
PubMed
Summary

Electronic whiteboards in emergency departments (EDs) increased time nurses, but not physicians, spent with patients. Implementation factors significantly influenced these work practice changes.

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Area of Science:

  • Healthcare Management
  • Clinical Informatics
  • Nursing Practice

Background:

  • Emergency departments (EDs) face challenges in optimizing clinician workflow and patient interaction.
  • Electronic whiteboards are increasingly adopted to enhance communication and efficiency in healthcare settings.

Purpose of the Study:

  • To evaluate the impact of electronic whiteboards on the time physicians and nurses spend in patient rooms versus at the control desk in an ED.
  • To understand how electronic whiteboards influence clinical work practices and mental workload.

Main Methods:

  • Observational study comparing time allocation before and after electronic whiteboard implementation in an ED.
  • Data collection on time spent in patient rooms and at the control desk by physicians and nurses.
  • Qualitative assessment of implementation factors and clinician experience.

Main Results:

  • Nurses significantly increased time spent in patient rooms (28%) after four months, while physicians did not (20%).
  • Observed changes were contingent on implementation specifics, existing workflows, and staff experience.
  • Distributed access to whiteboard information did not reduce the coordinating nurse's mental workload as anticipated.

Conclusions:

  • Electronic whiteboards can alter nurse-patient interaction time in EDs, but physician impact is less clear.
  • Successful integration requires addressing implementation challenges and tailoring to specific clinical environments.
  • Enhanced whiteboard functionality and robust implementation strategies are needed for broader workflow improvements.