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Related Concept Videos

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

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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...
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Data collection gathers information needed to make accurate judgments about a patient's present condition. During a health history interview, subjective data is collected from the patient, their caregivers, or family members, and objective data is collected through observations and physical assessment. Patients are the primary source of subjective data. Thus information gathered from patients through interviews, observations, and physical examination is primary data. Secondary sources of...
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Data Collection II01:29

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The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and...
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Data Collection III01:05

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The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.
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Data Reporting and Recording01:24

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Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...
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Methods of Documentation I: Source-Oriented Records01:18

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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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A Platform to Collect Structured Data from Multiple EMRs.

Ahmad Ghany1, Karim Keshavjee1

  • 1InfoClin Inc, Toronto, ON.

Studies in Health Technology and Informatics
|February 14, 2015
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Summary
This summary is machine-generated.

Canadian Electronic Medical Records (EMRs) generate vast data, but it lacks standardization for research and healthcare management. A new platform design aims to capture structured data from all EMRs for improved care and system insights.

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Area of Science:

  • Health Informatics
  • Health Systems Research
  • Data Management

Background:

  • Electronic Medical Records (EMRs) adoption is increasing in Canada, generating large datasets.
  • Current EMR data is often unstructured, hindering research, surveillance, and health system management.
  • Lack of standardized, accessible data limits real-time impact at the point of care.

Purpose of the Study:

  • To design a scalable platform for capturing structured, evidence-based data from Canadian Electronic Medical Records (EMRs).
  • To facilitate data accessibility for research, health system management, and clinical decision support.
  • To provide real-time guideline advice to healthcare providers at the point of care.

Main Methods:

  • An iterative joint design process involving 90 diverse stakeholders.
  • Incorporation of stakeholder feedback to develop platform specifications.
  • Utilizing clinical forms for data capture and guideline delivery.

Main Results:

  • A scalable platform design for structured data capture from multiple EMRs across Canada.
  • The platform enables structured, high-quality data collection and real-time clinical decision support.
  • The design addresses scalability across various diseases and EMR systems.

Conclusions:

  • The proposed platform offers a solution for standardized data capture and utilization from Canadian EMRs.
  • It enhances research capabilities, health system management, and point-of-care clinical decision support.
  • The design considers scalability, stakeholder needs, privacy, and security.