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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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Every measurement provides three kinds of information: the size or magnitude of the measurement (a number), a standard of comparison for the measurement (a unit), and an indication of the uncertainty of the measurement. While the number and unit are explicitly represented when a quantity is written, the uncertainty is an aspect of the errors in the measurement results.
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Methods of Documentation II: POMR01:26

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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.
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Methods of Documentation III: PIE01:21

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Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:
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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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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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Related Experiment Video

Updated: Feb 7, 2026

A Laboratory Method to Measure Contagious Yawning in Rats
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Compliance Is Contagious: Using Informatics Methods to Measure the Spread of a Documentation Standard From a

Daniel H Hagaman, Jesse M Ehrenfeld, Maxim Terekhov

    Journal of Perianesthesia Nursing : Official Journal of the American Society of Perianesthesia Nurses
    |August 6, 2018
    PubMed
    Summary

    Standardizing preoperative documentation in a clinic improved adherence and positively impacted perioperative care. This initiative enhanced clinical management and care coordination through a phased intervention.

    Keywords:
    history of present illnessinformaticspreoperative evaluationstandardization

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    Area of Science:

    • Healthcare informatics
    • Clinical process improvement
    • Perioperative medicine

    Background:

    • Preoperative documentation is critical for coordinated patient care.
    • Standardization of documentation can enhance clinical management.
    • Current documentation practices may lack consistency.

    Purpose of the Study:

    • To assess the impact of a preoperative documentation standardization intervention.
    • To evaluate the effectiveness of standardization beyond the preoperative clinic.
    • To identify factors influencing the adoption of standardized documentation.

    Main Methods:

    • An observational pre/post standardization design was employed.
    • A phased intervention included clinician education, feedback, and a compliance dashboard.
    • A follow-up survey measured the impact on clinical management.

    Main Results:

    • Adherence to standardized preoperative documentation improved with electronic feedback.
    • The intervention significantly impacted clinical management outside the preoperative clinic.
    • Trainee status was a key predictor of adopting the standardized format.

    Conclusions:

    • Implementing a preoperative documentation standard positively influenced perioperative system practices.
    • Standardization efforts in preoperative settings can yield broader system benefits.
    • The study highlights the importance of feedback and performance evaluation in driving adoption.