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Related Concept Videos

Methods of Documentation III: PIE01:21

Methods of Documentation III: PIE

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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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Nursing Evaluation01:15

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The evaluation stage signals the end of the nursing process. The nurse gathers evaluative data to assess whether or not the patient has attained the expected results. Whereas the nurse collects data in the nursing assessment to identify the patient's health concerns, the evaluation stage data determines if the indicated health issues are resolved. Evaluative data collection includes two sections: the data acquired to evaluate patient outcomes and the time criteria for data collection.
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Nursing Process for Patient and Caregiver Teaching III: Evaluation and Documentation01:20

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Evaluation of the teaching process enables the nurse to determine if the patient's learning needs were met and if training was effective. If the expected outcomes are not met, the care plan is revised, and additional education or reinforcement is provided. Nurses can ask questions after the session or obtain feedback to assess the patient's understanding of the topic.
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A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
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Methods of Documentation V: CBE01:23

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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 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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A Cross-Disciplinary and Multi-Modal Experimental Design for Studying Near-Real-Time Authentic Examination Experiences
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Patients Evaluate Visit Notes Written by Their Clinicians: a Mixed Methods Investigation.

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  • 1College of Nursing and Health Sciences, University of Massachusetts, Boston, MA, USA.

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|July 17, 2020
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Summary

Patients largely understand their open notes and find them accurate. However, poor understanding or inaccuracies reduce patient confidence and willingness to recommend clinicians, highlighting areas for improvement in clinical documentation.

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Area of Science:

  • Health Informatics
  • Patient Engagement
  • Clinical Communication

Background:

  • Patient involvement in care correlates with improved health outcomes.
  • Open notes, or patients accessing their clinical visit notes online, are increasingly common.
  • Understanding of these notes by patients remains largely unexamined.

Purpose of the Study:

  • To evaluate patient perceptions of clarity, accuracy, and completeness of open notes.
  • To gather patient suggestions for improving clinical note quality.
  • To explore the link between patient understanding of notes and their likelihood to recommend clinicians.

Main Methods:

  • An online survey was distributed to patients across three large health systems.
  • Data were collected from June to October 2017.
  • A mixed-methods analysis was performed on responses from 21,664 adult patients who had read an open note within the past year.

Main Results:

  • Nearly all patients (96%) reported understanding their notes well.
  • A high percentage (93%) found the notes accurately described their visit.
  • Common improvement suggestions focused on note structure, content, jargon, and accuracy; poor understanding or perceived inaccuracies significantly decreased clinician recommendation likelihood.

Conclusions:

  • Patients generally understand and trust their open notes, with minimal sociodemographic disparities.
  • Patients offer valuable feedback for enhancing note quality, particularly regarding clarity and accuracy.
  • Addressing comprehension and accuracy issues in open notes is crucial for maintaining patient trust and positive clinician relationships.