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Related Concept Videos

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 VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

1.0K
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.
For example, a patient with a chronic...
1.0K
Methods of Documentation IV: Focus Charting01:26

Methods of Documentation IV: Focus Charting

1.8K
Focus Charting, also known as the focus charting system or "focus documentation," is a systematic documentation approach used in healthcare to organize patient information in medical records.
It typically involves three columns for recording information:
1.8K
Nursing Clinical Information System01:27

Nursing Clinical Information System

1.4K
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.
Critical attributes of NCIS include:
1.4K
Data Reporting and Recording01:24

Data Reporting and Recording

5.6K
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...
5.6K
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

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Related Experiment Video

Updated: Mar 25, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

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[Process and method for CDISC-based CRF annotation].

Hong-wei Wang, Ya-zhong Deng, Daniel Liu

    Yao Xue Xue Bao = Acta Pharmaceutica Sinica
    |February 26, 2016
    PubMed
    Summary
    This summary is machine-generated.

    CDISC-based Case Report Form (CRF) annotation is crucial for clinical trial database setup and regulatory submissions. This paper details the essential components, processes, and guidelines for CDISC-based CRF annotation.

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    Area of Science:

    • Clinical data management
    • Regulatory science
    • Biomedical informatics

    Background:

    • CRF annotation is vital for database setup and data verification.
    • STDM-based CRF annotation is essential for regulatory data package submission.

    Purpose of the Study:

    • To describe the contents of CDISC-based CRF annotation.
    • To outline the procedures for CDISC-based CRF annotation.
    • To discuss related stipulations for CDISC-based CRF annotation.

    Main Methods:

    • Review of CDISC standards for CRF annotation.
    • Analysis of typical CRF annotation content.
    • Description of procedural steps in annotation.

    Main Results:

    • Detailed explanation of CDASH-based annotation for database setup.
    • Explanation of STDM-based annotation for regulatory submissions.
    • Identification of key procedural elements and stipulations.

    Conclusions:

    • CDISC-based CRF annotation is a critical component of clinical trial data management.
    • Standardized annotation ensures data integrity and facilitates regulatory review.
    • Understanding annotation content, procedures, and stipulations is essential for successful trials.