Related Concept Videos
01:26Methods of Documentation IV: Focus Charting
1.2K
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:
It typically involves three columns for recording information:
1.2K
01:18Guidelines and Strategies for Safe Computer Charting
903
The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Maintain Confidentiality and Security:
903
01:26Guidelines for Nursing Documentation II
1.2K
Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
1.2K
01:17Flow Sheet
2.0K
Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
2.0K
01:06Legal Guidelines for Documentation
1.5K
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
1.5K
01:18Methods of Documentation I: Source-Oriented Records
1.2K
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:
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:
1.2K
You might also read
Related Articles
Articles linked to this work by shared authors, journal, and citation graph.
Sort by
Same author
Feasibility of Tailoring Artificial Intelligence-Assisted Ambient Scribes for Intensive Care Unit Rounds: Algorithm Development and Validation.
JMIR medical informatics·2026
Same author
Title: Multimodal Fusion of Clinical and Imaging Data for Early Prediction of Massive Transfusion in Trauma.
AMIA Joint Summits on Translational Science proceedings. AMIA Joint Summits on Translational Science·2026
Related Experiment Video
Updated: Sep 29, 2025
05:04
Author Spotlight: Evaluating Clinicians' Adoption of Ultrasound-Guided Vascular Cannulation Through Simulation Training
Published on: August 9, 2024
1.1K
Chart Completion Time of Attending Physicians While Using Medical Scribes.
Sarah T Florig1, Sky Corby1, Nicholas T Rosson1
1Oregon Health & Science University, Portland, OR, USA.
AMIA ... Annual Symposium Proceedings. AMIA Symposium
|March 21, 2022
Summary
Medical scribes streamline electronic health record documentation, but this study found significant variability in chart completion times across specialties and individual providers. More research is needed to understand these differences.
Area of Science:
- Health Informatics
- Clinical Workflow Optimization
- Medical Documentation
Background:
- Medical scribes are increasingly utilized to enhance provider efficiency in electronic health record (EHR) documentation.
- Existing literature on the impact of scribes on documentation completion time is limited.
- Variability in clinical workflows necessitates an understanding of scribe impact on documentation efficiency.
Purpose of the Study:
- To investigate the impact of medical scribes on chart completion time.
- To identify variations in documentation completion time among providers using scribes.
- To analyze differences in completion time across various clinical specialties and settings.
Main Methods:
- Retrospective, descriptive study design.
- Analysis of 148,410 scribed encounters from 55 clinics.
- Examination of chart completion time data across different specialties and providers.
Main Results:
- Significant variance in chart completion time was observed between different specialty groups.
- Substantial variability in completion time existed among providers within the same clinic.
- These patterns of variability were consistent across all analyzed specialties.
Conclusions:
- Utilizing medical scribes introduces a higher degree of variability in chart completion time than previously expected.
- Further investigation is warranted to understand the factors contributing to this variability.
- Optimizing scribe utilization may require tailored approaches based on specialty and individual provider needs.