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Related Concept Videos

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:
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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 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.
It typically involves three columns for recording information:
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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 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.
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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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Beyond Notes: Why It Is Time to Abandon an Outdated Documentation Paradigm.

Jackson Steinkamp1, Jacob Kantrowitz2, Abhinav Sharma3

  • 1Department of Medicine, University of Pennsylvania, Philadelphia, PA, United States.

Journal of Medical Internet Research
|April 20, 2021
PubMed
Summary
This summary is machine-generated.

This viewpoint proposes organizing electronic medical notes by topic, not time, to improve clinician efficiency. This collaborative framework enhances patient assessment and data retrieval, boosting healthcare delivery.

Keywords:
clinicianselectronic medical noteselectronic medical recordshealth informaticsinformation chaosmedical documentationmedical notesmedical team

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Area of Science:

  • Health Informatics
  • Clinical Workflow Optimization
  • Medical Documentation Systems

Background:

  • Clinicians dedicate significant time to reviewing and writing electronic medical notes.
  • Current electronic medical note organization is suboptimal for individual clinicians and medical teams.
  • Existing frameworks often hinder efficient data access and patient assessment.

Purpose of the Study:

  • To propose a reconceptualization of the electronic medical record (EMR) structure.
  • To advocate for a topic-based, collaborative workspace over traditional time- or writer-based organization.
  • To highlight the potential for improved healthcare delivery effectiveness and efficiency.

Main Methods:

  • This viewpoint discusses a paradigm shift in EMR organization.
  • It proposes organizing the medical chart (notes, labs, imaging) as a dynamic, collaborative workspace.
  • The proposed framework prioritizes topic-based organization over chronological or author-based structures.

Main Results:

  • The topic-based framework facilitates more accurate and complete patient state assessments.
  • It enables easier and faster historical data review.
  • Clinicians can achieve substantial time savings in both data input and retrieval.

Conclusions:

  • Reorganizing electronic medical notes by topic offers significant advantages over current systems.
  • This approach enhances clinical efficiency and reduces time spent on documentation and data retrieval.
  • The proposed collaborative workspace has the potential to improve overall healthcare delivery.