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Methods of Documentation IV: Focus Charting01:26

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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.
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Methods of Documentation II: POMR01:26

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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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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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Problem-oriented charting: A review.

Shilpa M Chowdhry1, Rebecca G Mishuris2, Devin Mann3

  • 1Department of Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, United States.

International Journal of Medical Informatics
|May 29, 2017
PubMed
Summary
This summary is machine-generated.

Problem-oriented charting organizes patient data by diagnosis. This review critically evaluates its history, current use, and offers insights for future research in medical documentation.

Keywords:
DocumentationElectronic medical recordsProblem listProblem-oriented medical records

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Area of Science:

  • Medical Informatics
  • Clinical Documentation

Background:

  • Problem-oriented charting is a method of medical documentation.
  • It organizes patient information based on diagnoses or specific health problems.

Purpose of the Study:

  • To review the history and current applications of problem-oriented charting.
  • To critically evaluate existing literature on this documentation method.
  • To offer insights from institutional experience and suggest future research directions.

Main Methods:

  • Literature review and critical evaluation of existing studies on problem-oriented charting.
  • Analysis of institutional practices regarding problem-oriented charting.

Main Results:

  • Problem-oriented charting provides a structured approach to organizing patient data.
  • The review critically assesses the efficacy and challenges of this method.
  • Institutional insights highlight practical applications and areas for improvement.

Conclusions:

  • Problem-oriented charting remains a relevant method for organizing patient medical information.
  • Further research is needed to optimize its use and explore new applications in healthcare settings.