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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,...
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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.
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The issues and trends in healthcare delivery are constantly changing. The COVID-19 pandemic is one recent issue that wreaked havoc on healthcare systems, causing a shortage of healthcare workers, high demand for medicines and supplies, and increased medical expenditure due to a lack of insurance. Other issues include rising healthcare costs and care fragmentation.
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Related Experiment Video

Updated: May 9, 2026

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
09:00

TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients

Published on: April 13, 2021

Developing and implementing an interoperable document-based electronic health record.

Fernando Campos1, Fernando Plazzotta, Daniel Luna

  • 1Health InformationDepartment, Hospital Italiano de Buenos Aires, Argentina.

Studies in Health Technology and Informatics
|August 8, 2013
PubMed
Summary

This study introduces a new architecture for health information exchange, enhancing data integrity and context using the Clinical Document Architecture (CDA) standard. This improves secure data sharing and reduces the need for paper records.

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Area of Science:

  • Health Informatics
  • Data Management
  • Clinical Documentation

Background:

  • Current health information exchange methods often lack data integrity and contextual metadata.
  • Existing systems frequently use partial or summary data, compromising authenticity.
  • There is a need for robust, secure, and context-rich health data sharing solutions.

Purpose of the Study:

  • To propose an alternative architecture for health information exchange integrated with electronic health records.
  • To enhance the authenticity, integrity, and contextual metadata of exchanged health information.
  • To leverage the Clinical Document Architecture (CDA) standard for a scalable and secure data repository.

Main Methods:

  • Developed a parallel architecture integrated with traditional electronic health records.
  • Utilized the Clinical Document Architecture (CDA) standard for data representation.
  • Implemented a relational data model for the clinical data repository.

Main Results:

  • Created a scalable, document-based electronic clinical data repository.
  • Ensured secure and controlled access to shared health information.
  • Achieved a redundant clinical data repository that remains unchanged over time.
  • Reduced the reliance on printing charts due to the portability of the CDA standard.

Conclusions:

  • The proposed architecture effectively addresses challenges in health information exchange authenticity and integrity.
  • The CDA standard facilitates secure, scalable, and context-rich sharing of clinical data.
  • This approach enhances data accessibility for patients, institutions, and healthcare professionals while reducing costs.