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

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

1.5K
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...
1.5K
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
Data Collection I01:30

Data Collection I

8.8K
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...
8.8K
Issues And Trends In Healthcare Delivery System01:29

Issues And Trends In Healthcare Delivery System

6.3K
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.
Cost Containment
Payment for healthcare services has historically promoted adoption of costly and often unnecessary or inefficient...
6.3K
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
Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

1.9K
The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
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 Versus Late Recurrence in Olfactory Neuroblastoma: A Multi-Institutional Analysis of Predictive Risk Factors.

International forum of allergy & rhinology·2026
Same author

Scoping Review of Global Kidney Genetics Clinic Models and Outcomes.

Kidney international reports·2026
Same author

Exploring fibronodular hepatocellular carcinoma: a case series investigating histopathologic and clinical characteristics and its potential association with cirrhosis.

American journal of clinical pathology·2026
Same author

KCNQ2 neonatal epilepsy: Impact of prompt diagnosis and treatment, and early predictors of outcome severity.

Epilepsia open·2026
Same author

Clinical application of artificial intelligence algorithms in detecting clival remodeling in the setting of pituitary neuroendocrine tumors/pituitary adenomas.

Frontiers in neurology·2026
Same author

Managing Alpha-Gal Allergy in a Case of Bioprosthetic TAVR.

Case reports in immunology·2026

Related Experiment Video

Updated: Mar 12, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
07:50

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

Published on: September 20, 2018

16.6K

Natural Language Processing-Enabled and Conventional Data Capture Methods for Input to Electronic Health Records: A

David R Kaufman1, Barbara Sheehan2, Peter Stetson3

  • 1Department of Biomedical Informatics, Arizona State University, Scottsdale, AZ, United States.

JMIR Medical Informatics
|October 30, 2016
PubMed
Summary

Natural language processing (NLP) significantly reduced electronic health record (EHR) documentation time and improved usability. This NLP-enabled dictation method shows promise for enhancing clinician experience while maintaining documentation quality.

Keywords:
electronic health recordsmedical transcriptionnatural language processinguser-computer interface

More Related Videos

Methodology for Establishing a Community-Wide Life Laboratory for Capturing Unobtrusive and Continuous Remote Activity and Health Data
11:21

Methodology for Establishing a Community-Wide Life Laboratory for Capturing Unobtrusive and Continuous Remote Activity and Health Data

Published on: July 27, 2018

8.9K
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

5.5K

Related Experiment Videos

Last Updated: Mar 12, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
07:50

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

Published on: September 20, 2018

16.6K
Methodology for Establishing a Community-Wide Life Laboratory for Capturing Unobtrusive and Continuous Remote Activity and Health Data
11:21

Methodology for Establishing a Community-Wide Life Laboratory for Capturing Unobtrusive and Continuous Remote Activity and Health Data

Published on: July 27, 2018

8.9K
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

5.5K

Area of Science:

  • Medical Informatics
  • Clinical Documentation Improvement
  • Natural Language Processing Applications

Background:

  • Electronic health records (EHRs) documentation is often time-consuming and inefficient.
  • Dictation with manual transcription is a common but burdensome practice.
  • Natural Language Processing (NLP) offers a potential alternative for efficient EHR data entry.

Purpose of the Study:

  • To evaluate the comparative effectiveness of NLP-enabled data capture versus standard EHR entry.
  • To assess impacts on documentation time, quality, and usability.
  • To compare a novel NLP dictation protocol against standard keyboard-mouse methods.

Main Methods:

  • A formative study compared four EHR data capture protocols, including NLP-NLP, Standard-Standard, NLP-Standard, and Standard-NLP.
  • Thirty-one specialists (neurologists, cardiologists, nephrologists) documented notes using each protocol.
  • Data collected included time on task, documentation quality (PDQI-9), and usability.

Main Results:

  • The NLP-NLP protocol significantly reduced documentation time across specialties compared to Standard-Standard.
  • NLP-NLP showed comparable or improved documentation quality scores on 8 of 9 metrics.
  • Usability scores were higher for the NLP-NLP protocol (mean 36.7) versus Standard-Standard (mean 30.3).

Conclusions:

  • An NLP-enabled dictation approach is feasible and demonstrates potential for reducing EHR documentation time.
  • This method may enhance EHR usability without compromising documentation quality.
  • NLP-based tools are poised to improve the EHR documentation process and user experience.