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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.
In CBE, healthcare professionals establish predefined standards of practice that define what constitutes...
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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

Methods of Documentation VI: Case Management Model

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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.
For example, a patient with a chronic...
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Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

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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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Methods of Documentation I: Source-Oriented Records01:18

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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:
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Periodic reflections: a method of guided discussions for documenting implementation phenomena.

Erin P Finley1,2,3, Alexis K Huynh4,5, Melissa M Farmer4,5

  • 1South Texas Veterans Health Care System, San Antonio, Texas, USA. finleye@uthscsa.edu.

BMC Medical Research Methodology
|November 29, 2018
PubMed
Summary
This summary is machine-generated.

This study introduces periodic reflections, an ethnographically-informed method to capture real-time implementation data in healthcare settings. This low-burden approach aids in understanding complex intervention rollouts and informing future strategies.

Keywords:
Complexity scienceEthnographyImplementation contextQualitative methodsReplicating effective programsWomen veterans; adaptation

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Area of Science:

  • Implementation Science
  • Qualitative Research Methods
  • Healthcare Management

Background:

  • Ethnography offers insights into healthcare implementation but is often time-intensive.
  • Pragmatic implementation research requires efficient methods to capture dynamic contexts.
  • Existing methods for integrating ethnographic insights into implementation are limited.

Purpose of the Study:

  • To describe an ethnographically-informed method of guided periodic reflections.
  • To assess the utility of periodic reflections for documenting implementation phenomena.
  • To support a multi-project national implementation program in VA women's health.

Main Methods:

  • Developed a lightly-structured method of guided "periodic reflections" based on ethnographic principles.
  • Conducted 30-60 minute telephone discussions with implementation teams at regular intervals.
  • Coded discussion notes to identify key domains and emergent themes for analysis.

Main Results:

  • Thirty reflections were completed over 15 months, covering pre-implementation to sustainment phases.
  • Reflections provided near-real-time data on implementation context, adaptations, and team sensemaking.
  • The method facilitated recurring reflection and problem-solving for implementation teams.

Conclusions:

  • Periodic reflections offer a straightforward, low-burden method for documenting implementation processes.
  • This approach effectively captures context, unfolding processes, sensemaking, and diverse viewpoints.
  • Periodic reflections are valuable for an ethnographically-minded implementation strategy in complex healthcare settings.