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Related Concept Videos

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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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 IV: Focus Charting01:26

Methods of Documentation IV: Focus Charting

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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:
1.1K
Data Reporting and Recording01:24

Data Reporting and Recording

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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...
4.7K
Methods of Documentation III: PIE01:21

Methods of Documentation III: PIE

1.4K
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:
1.4K
Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

2.0K
Documentation is the systematic process of formally recording, maintaining, and communicating information.
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive...
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Documentation: Back to Basics and Beyond

Lynn S Muller1

  • 1Lynn S. Muller, JD, BA-HCM, RN, CCM, began her career at Pace University as a registered professional nurse (RN), went onto earn her Bachelor of Arts degree in Health Care Management at St. Peter's University of New Jersey and then her Juris Doctor from Quinnipiac University School of Law. She is currently a practicing attorney and the managing partner of Muller & Muller. Her practice includes defense of health care professionals before the state licensing boards, case management litigation, family law, wills, trusts, and estates, as well as consulting representation of medical practitioners, facilities, and health service corporations on such issues as regulatory compliance and day-to-day operations. Dr. Muller is a popular and sought-after keynote and session speaker at national and regional conferences. She is the Contributing Editor of Professional Case Management : The Official Journal of the Case Management Society of America (CMSA) and the Commission for Case Management Certification (CCMC), a former member of the Board of Directors of CMSA of New York City. She is an adjunct professor at St. Peter's University School of Nursing in the MSN and DNP programs. Dr. Muller is the author of more than 80 articles in nursing and case management journals and listed on the NIH website. She is a contributor to the 2016 CMSA Standards of Practice and CMSA Career & Knowledge Pathways. Dr. Muller is the author of both legal chapters of the third edition of Case Management: A Practical Guide for Education and Practice and the third edition of the CMSA Core Curriculum for Case Management . She is a former commissioner for the Commission for Case Management Certification (CCMC), where she now serves on the Professional Development and Education Committee, is a certified facilitator for CCM CERTIFCATION 360, a Multi-day Immersion Program, and other special projects. She is a contributor to the CCMC Case Management Body of Knowledge (CMBOK) and a past president of the New Jersey Chapter of CMSA. Dr. Muller is the former Director of Social Services for the Borough of Bergenfield, NJ, a community-based case management program she developed and initiated. Dr. Muller has also served her community as public defender, municipal court judge, and councilwoman and chaired the Borough's Barrier Free Committee.

Professional Case Management
|July 24, 2023
PubMed
Summary

No abstract available in PubMed .

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