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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 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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Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

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Documentation in long-term care facilities and home healthcare settings is crucial for ensuring continuous, coordinated, and comprehensive care for patients. Each setting has its specific documentation processes and tools:
Long-Term Care Facilities
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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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Formats for Nursing Documentation01:28

Formats for Nursing Documentation

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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,...
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Related Experiment Video

Updated: Sep 4, 2025

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
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Developing a Feasible and Credible Method for Analyzing Healthcare Documents as Written Data.

Tanja Moilanen1, Mari Sivonen2, Kirsi Hipp3

  • 1University of Turku, Finland.

Global Qualitative Nursing Research
|July 14, 2022
PubMed
Summary

This study introduces a seven-phase methodological framework for analyzing healthcare documents as written data. This framework enhances the feasibility and credibility of document analysis in health and nursing research.

Keywords:
credibilitydocument analysisfeasibilitymethodologysystematic methodological reviewwritten data

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Area of Science:

  • Health Sciences
  • Nursing Sciences
  • Qualitative Research

Background:

  • Healthcare generates vast amounts of written documents often underutilized in research.
  • Limited guidance exists for the systematic analysis of healthcare documents as data.
  • Document analysis is crucial for health and nursing sciences research.

Purpose of the Study:

  • To provide a methodological framework for analyzing healthcare documents as written data.
  • To enhance the systematic approach to document analysis in health and nursing research.
  • To ensure the feasibility and credibility of document analysis studies.

Main Methods:

  • Systematic methodological review.
  • Incorporation of research team's practical experience.
  • Development of a seven-phase framework for document analysis.

Main Results:

  • A seven-phase framework for analyzing healthcare documents was developed.
  • The phases include: identifying purpose, document selection, extraction matrix design, pilot testing, data collection and analysis, credibility assessment, and ethical considerations.
  • The framework offers a structured approach to document analysis.

Conclusions:

  • The developed framework provides a feasible and credible method for document analysis in healthcare research.
  • It addresses the underutilization of written documents in health and nursing sciences.
  • The framework supports rigorous qualitative research using textual data.