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Related Concept Videos

Data Collection I01:30

Data Collection I

7.6K
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...
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Data Collection II01:29

Data Collection II

9.4K
The nursing history captures and records the patient's health status, so that a care plan evolves to meet the patient's individual needs. The nursing health history is a part of the initial assessment. A comprehensive history covers all health dimensions and plays a significant role in the assessment process. A comprehensive history includes the patient's biographical information, reasons for seeking health care, expectations, present and past health history, medications, and...
9.4K
Methods of Documentation I: Source-Oriented Records01:18

Methods of Documentation I: Source-Oriented Records

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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:
1.5K
Formats for Nursing Documentation01:28

Formats for Nursing Documentation

1.6K
Nursing documentation encompasses various formats designed to capture precise patient data, facilitate communication among healthcare team members, and ensure comprehensive and accurate patient records. Let's explore each of these formats in detail:
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
1.6K
Data Reporting and Recording01:24

Data Reporting and Recording

5.2K
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...
5.2K
Data Collection III01:05

Data Collection III

3.8K
The physical assessment examines the patient for objective data that defines the patient's condition, and aids in formulating the nursing care plan. The purpose of physical assessment is a health status appraisal, which includes identifying health problems, and establishing a database for nursing intervention.
The principles to begin the physical assessment include conducting a comprehensive or problem-related history in a quiet, well-lit room, emphasizing privacy and comfort for the...
3.8K

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Generation of Comprehensive Thoracic Oncology Database - Tool for Translational Research
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Structured Data Capture for Oncology.

Alexander K Goel1, Walter Scott Campbell2, Richard Moldwin1

  • 1Cancer Protocols and Data Standards, College of American Pathologists, Northfield, IL.

JCO Clinical Cancer Informatics
|February 16, 2021
PubMed
Summary
This summary is machine-generated.

Structured Data Capture (SDC) offers a standardized framework for collecting and exchanging healthcare data at the point of care. Mapping SDC data to terminologies like SNOMED CT enhances data usability for oncology and other clinical applications.

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Area of Science:

  • Healthcare Informatics
  • Medical Informatics
  • Health Data Standards

Background:

  • Healthcare informatics faces significant challenges due to a lack of data interoperability.
  • Current interoperability efforts often overlook data capture standardization, focusing mainly on data transmission.
  • Standardizing data capture is crucial for seamless data exchange and utilization.

Purpose of the Study:

  • To introduce Structured Data Capture (SDC) as an open-source framework for standardized data capture and exchange.
  • To highlight SDC's role in preserving data integrity (semantic, contextual, structural) throughout its lifecycle.
  • To demonstrate SDC's applicability in complex data scenarios, particularly in oncology.

Main Methods:

  • Utilizing eXtensible Markup Language (XML) for SDC documents, ensuring computer readability and technology agnosticism.
  • Implementing SDC to enable the creation and exchange of interoperable data entry forms (DEFs).
  • Mapping SDC data elements to standard terminologies, such as SNOMED CT, to enhance data usability and enable advanced querying.

Main Results:

  • SDC facilitates the capture and exchange of standardized, structured data via interoperable DEFs.
  • SDC documents are technology-agnostic and can be rendered into DEFs or synoptic reports by any SDC-capable system.
  • Mapping SDC data to SNOMED CT allows for data aggregation and advanced analysis based on standardized concepts.

Conclusions:

  • SDC provides a robust solution for interoperable data capture and exchange across various healthcare needs, including patient care, clinical trials, and public health.
  • The framework supports the preservation of data integrity from capture to long-term use.
  • Enhancing SDC data usability through terminology mapping is key for advanced clinical research and care guideline implementation.