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Related Concept Videos

Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

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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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Methods of Documentation VI: Case Management Model01:15

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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.
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Nursing Clinical Information System (NCIS)
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Formats for Nursing Documentation01:28

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Methods of Documentation IV: Focus Charting01:26

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Methods of Documentation VII: EMR01:30

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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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Cross-institutional document exchange system using clinical document architecture (CDA) with virtual printing method.

Naoki Mihara1, Kanayo Ueda2, Shirou Manabe1

  • 1Graduate School of Medicine, Department of Integrated Medicine, Medical Informatics, Osaka University, Osaka, Japan.

Studies in Health Technology and Informatics
|May 21, 2015
PubMed
Summary
This summary is machine-generated.

Healthcare information exchange in Japan is inefficient, relying on paper documents. We developed a new system for cross-institutional document exchange using Clinical Document Architecture (CDA) and virtual printing to streamline patient data sharing.

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Area of Science:

  • Medical Informatics
  • Health Information Exchange
  • Electronic Health Records

Background:

  • Current healthcare information exchange in Japan heavily relies on paper-based referral documents.
  • This manual process involves printing, sending, and scanning, leading to inefficiencies and potential data loss.
  • The lack of a standardized electronic system hinders seamless patient data sharing between institutions.

Purpose of the Study:

  • To address the inefficiencies in Japanese healthcare information exchange.
  • To develop a novel system for cross-institutional document exchange.
  • To improve the accessibility and integrity of patient medical records across different hospitals.

Main Methods:

  • Development of a cross-institutional document exchange system.
  • Utilization of Clinical Document Architecture (CDA) for standardized data formatting.
  • Implementation of a virtual printing method for seamless document transfer.

Main Results:

  • The developed system facilitates efficient electronic exchange of patient information.
  • Virtual printing eliminates the need for manual printing and scanning of documents.
  • CDA ensures standardized and structured clinical document data.

Conclusions:

  • The developed system offers a more efficient and streamlined approach to healthcare information exchange in Japan.
  • This solution can significantly reduce administrative burden and improve the quality of patient care.
  • Adoption of CDA and virtual printing presents a viable model for modernizing health data interoperability.