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Methods of Documentation VII: EMR

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,...

Techniques of Therapeutic Communication II: Focusing, Paraphrasing, and Summarizing

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Focusing involves centering a conversation on a message's critical elements or concepts. Focusing is valuable if the talk is vague or patients begin to repeat themselves. Sometimes, when patients are asked about their symptoms, they may go off-topic and try to tell their entire life story. Respectfully, the nurse should bring the conversation back into focus.
This therapeutic technique can also be used when a patient brings up pertinent information during a health-related conversation. The...

Documentation of Nursing Diagnosis

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...

Nursing Clinical Information System

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.
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Health Literacy

Health Literacy

Health literacy is an individual's or a community's capacity to comprehend, receive, read, and use relevant healthcare information and services. The World Health Organization (WHO, 2018) defines health literacy as the cognitive and social skills that determine the ability of individuals to gain access to, understand, and use information in ways that promote and maintain good health. As a result, the WHO helps individuals manage long-term health concerns, participate in preventative programs,...

Formats for Nursing Documentation

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:
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Updated: May 9, 2026

E-Patient Counseling Trial (E-PACO): Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

E-Patient Counseling Trial (E-PACO): Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

Published on: August 1, 2019

Improving patients' electronic health record comprehension with NoteAid.

Balaji Polepalli Ramesh¹, Thomas Houston, Cynthia Brandt

¹Biomedical and Health Informatics, University of Wisconsin Milwaukee, Milwaukee, WI, USA.

Studies in Health Technology and Informatics

|August 8, 2013

Summary

This summary is machine-generated.

Patients can now understand their electronic health record (EHR) notes better. A new system, NoteAid, simplifies medical jargon using resources like Wikipedia, improving patient comprehension and healthcare outcomes.

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Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform

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Published on: April 12, 2021

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E-Patient Counseling Trial (E-PACO): Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

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Published on: August 1, 2019

Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform

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Published on: April 12, 2021

Area of Science:

Biomedical Informatics
Natural Language Processing
Consumer Health Informatics

Background:

Direct patient access to electronic health record (EHR) notes can improve health literacy and outcomes.
EHR notes often contain complex medical terminology inaccessible to patients.
Bridging the gap between clinical documentation and patient understanding is crucial for effective healthcare.

Purpose of the Study:

To present NoteAid, a BioNLP system designed to simplify EHR notes for patients.
To automatically recognize medical concepts within EHR notes and link them to simplified definitions.
To evaluate the effectiveness of NoteAid in enhancing EHR note readability using external knowledge resources.

Main Methods:

Developed a BioNLP system (NoteAid) for medical concept recognition and definition linking.
Conducted a pilot evaluation linking EHR notes via NoteAid to MedlinePlus, UMLS, and Wikipedia.
Assessed the impact of linked definitions on EHR note readability.

Main Results:

Wikipedia integration significantly improved the readability of EHR notes.
MedlinePlus and UMLS require enhancements in content readability and coverage for consumer health information.
NoteAid demonstrated potential in making clinical notes more accessible.

Conclusions:

Automated simplification of EHR notes using external resources like Wikipedia can enhance patient understanding.
Further development is needed for resources like MedlinePlus and UMLS to effectively support patient comprehension of clinical information.
NoteAid offers a promising approach to improving patient engagement and health outcomes through accessible health records.