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Related Concept Videos

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,...
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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.
Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters assessment...
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 IV: Focus Charting01:26

Methods of Documentation IV: Focus Charting

Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:

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Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
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Challenges to depression care documentation in an EHR.

Amy M Kobus1, Jeffrey S Harman, Hau D Do

  • 1Department of Family Medicine, Oregon Health & Science University, Portland, OR 97239-3098, USA. kobusa@ohsu.edu

Family Medicine
|April 5, 2013
PubMed
Summary
This summary is machine-generated.

Electronic health records (EHR) often fail to capture crucial depression care details. Standardizing clinical documentation in EHRs is vital for efficient tracking and evaluation of patient treatment.

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Area of Science:

  • Primary care medicine
  • Health informatics
  • Clinical documentation

Background:

  • Depression is commonly diagnosed in primary care settings.
  • Electronic health records (EHR) offer potential for enhanced depression care management.
  • This study highlights EHR limitations in capturing essential depression care information.

Purpose of the Study:

  • To exemplify how EHR systems can inadequately document depression care.
  • To assess the completeness of depression care documentation within an EHR system.

Main Methods:

  • Identified adult patients with new depression diagnoses using ICD-9 codes in an EHR.
  • Conducted electronic data abstraction followed by manual chart reviews.
  • Evaluated depression screening, diagnosis, and treatment documentation across four family medicine clinics.

Main Results:

  • 200 adult patients with new depression diagnoses were identified electronically.
  • Manual chart review revealed significant gaps in documented screening (9%) and diagnostic tool use (73%).
  • Documentation for treatment options (83%), medication (71%), and follow-up (75%) was also incomplete.

Conclusions:

  • Despite a robust EHR, significant challenges exist in documenting depression care.
  • Incomplete EHR documentation hinders the tracking and evaluation of evidence-based depression treatment.
  • Simplifying and standardizing clinical documentation is necessary for efficient data extraction and performance monitoring.