Jove
Visualize
Contact Us
JoVE
x logofacebook logolinkedin logoyoutube logo
ABOUT JoVE
OverviewLeadershipBlogJoVE Help Center
AUTHORS
Publishing ProcessEditorial BoardScope & PoliciesPeer ReviewFAQSubmit
LIBRARIANS
TestimonialsSubscriptionsAccessResourcesLibrary Advisory BoardFAQ
RESEARCH
JoVE JournalMethods CollectionsJoVE Encyclopedia of ExperimentsArchive
EDUCATION
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab ManualFaculty Resource CenterFaculty Site
Terms & Conditions of Use
Privacy Policy
Policies

Related Concept Videos

Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

1.7K
Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
1.7K
Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

1.6K
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...
1.6K
Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

1.5K
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.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
1.5K
Methods of Documentation II: POMR01:26

Methods of Documentation II: POMR

1.6K
The Problem-Oriented Medical Record (POMR) revolutionized medical record-keeping by introducing a systematic approach focusing on the patient's problems rather than merely listing symptoms. Dr. Lawrence Weed's introduction of this method in the 1960s marked a significant advancement in medical documentation. The POMR framework consists of four key components: the database, problem list, plan of care, and progress notes.
1.6K
Formats for Nursing Documentation01:28

Formats for Nursing Documentation

2.2K
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:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
2.2K
Methods of Documentation I: Source-Oriented Records01:18

Methods of Documentation I: Source-Oriented Records

1.9K
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:
1.9K

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by
Same author

Early Postoperative Adverse Events (≤ 30 Days) in Spinal Oncology: Defining the Incidence, Severity, and Predictors in a Mixed Prospective Cohort Including Intradural and Metastatic Spinal Tumors.

International journal of cancer·2026
Same author

Clinical decision support in hematological malignancies using a case-grounded AI agent.

Nature medicine·2026
Same author

Quick assessment of quality-of-life in itch: An exploratory validation of the 5-item pruritus life quality.

Journal der Deutschen Dermatologischen Gesellschaft = Journal of the German Society of Dermatology : JDDG·2026
Same author

High-Frequency Global Postoperative Status PROMs Track Pain Peaks and Analgesic Use After Degenerative Lumbar Spine Surgery.

Global spine journal·2026
Same author

Early pain relief and segmental realignment after two-stage lateral lumbar interbody fusion (LLIF) with posterior instrumentation in degenerative lumbar pathology.

Neurosurgical review·2026
Same author

LLM4ODM: Synthetic Clinical Study Data Generation for CDISC ODM.

Studies in health technology and informatics·2026

Related Experiment Video

Updated: Apr 12, 2026

Expedited Radiation Biodosimetry by Automated Dicentric Chromosome Identification ADCI and Dose Estimation
10:33

Expedited Radiation Biodosimetry by Automated Dicentric Chromosome Identification ADCI and Dose Estimation

Published on: September 4, 2017

16.8K

ODM2CDA and CDA2ODM: tools to convert documentation forms between EDC and EHR systems.

Martin Dugas1

  • 1Institute of Medical Informatics, University of Münster, Albert-Schweitzer-Campus 1, A11, D-48149, Münster, Germany. dugas@uni-muenster.de.

BMC Medical Informatics and Decision Making
|May 26, 2015
PubMed
Summary

Automated conversion between Electronic Data Capture (EDC) Operational Data Model (ODM) and Clinical Document Architecture (CDA) is feasible. This facilitates data exchange between clinical trial and patient care systems, despite format differences.

More Related Videos

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation
04:58

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation

Published on: August 25, 2022

2.7K
Executing Complexity-Increasing Queries in Relational MySQL and NoSQL MongoDB and EXist Size-Growing ISO/EN 13606 Standardized EHR Databases
07:26

Executing Complexity-Increasing Queries in Relational MySQL and NoSQL MongoDB and EXist Size-Growing ISO/EN 13606 Standardized EHR Databases

Published on: March 19, 2018

9.8K

Related Experiment Videos

Last Updated: Apr 12, 2026

Expedited Radiation Biodosimetry by Automated Dicentric Chromosome Identification ADCI and Dose Estimation
10:33

Expedited Radiation Biodosimetry by Automated Dicentric Chromosome Identification ADCI and Dose Estimation

Published on: September 4, 2017

16.8K
Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation
04:58

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation

Published on: August 25, 2022

2.7K
Executing Complexity-Increasing Queries in Relational MySQL and NoSQL MongoDB and EXist Size-Growing ISO/EN 13606 Standardized EHR Databases
07:26

Executing Complexity-Increasing Queries in Relational MySQL and NoSQL MongoDB and EXist Size-Growing ISO/EN 13606 Standardized EHR Databases

Published on: March 19, 2018

9.8K

Area of Science:

  • Health Informatics
  • Biomedical Data Standards
  • Clinical Data Management

Background:

  • Electronic Data Capture (EDC) in clinical trials utilizes standards like Operational Data Model (ODM) from CDISC.
  • Electronic Health Record (EHR) systems primarily use HL7 standards, specifically Clinical Document Architecture (CDA), for patient care data.
  • Increasing volumes of patient data are managed electronically, necessitating interoperability between systems.

Purpose of the Study:

  • To explore the technical feasibility of converting data between ODM and CDA formats.
  • To address the need for seamless data flow between clinical trial and patient care electronic systems.

Main Methods:

  • Development and implementation of an open-source reference tool for ODM-CDA form conversion.
  • Analysis of the structural and design differences between ODM and CDA to identify conversion challenges.

Main Results:

  • An open-source implementation successfully converted forms between ODM and CDA formats.
  • Identified limitations in the conversion process stem from the distinct scope and hierarchical structures of ODM and CDA.
  • CDA's multi-level hierarchy and its nodes' capacity for both XML values and attributes present specific conversion complexities.

Conclusions:

  • Automated bidirectional transformation between ODM and CDA files is technically achievable.
  • While feasible, the conversion process requires careful consideration of the inherent differences in data modeling between the two standards.