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Related Concept Videos

Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

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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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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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Data Reporting and Recording01:24

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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...
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Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:  
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
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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.
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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:
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Updated: Jul 2, 2025

Integrating Augmented Reality Tools in Breast Cancer Related Lymphedema Prognostication and Diagnosis
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Structured Reporting: An Intervention to Improve Procedure Documentation in Breast Imaging.

Tyann L Floore1, Cherie M Kuzmiak1, Sheila S Lee1

  • 1University of North Carolina - Chapel Hill, Department of Radiology, Chapel Hill, NC, USA.

Journal of Breast Imaging
|February 28, 2024
PubMed
Summary
This summary is machine-generated.

Implementing structured reporting significantly improved documentation of breast biopsy markers, potentially reducing medical errors. This intervention enhanced the accuracy of marker and shape reporting in breast lesion biopsies.

Keywords:
biopsy markerbreast imagingcore-needle biopsystructured reporting

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Area of Science:

  • Radiology
  • Medical Informatics
  • Patient Safety

Background:

  • Wrong-site surgery can occur due to errors in localizing breast biopsy markers.
  • Accurate documentation of biopsy markers is crucial for preventing surgical errors.
  • Previous methods lacked consistent reporting of marker placement and characteristics.

Purpose of the Study:

  • To evaluate the impact of structured reporting on the documentation of breast biopsy markers.
  • To assess if structured reporting can reduce medical errors related to incorrect marker localization.
  • To improve the quality of reporting for breast lesions requiring biopsy markers.

Main Methods:

  • Retrospective review of breast core-needle biopsy reports from 2014 to 2020.
  • Patients divided into three cohorts: pre-intervention (2014), pre-intervention/post-sentinel (2017), and post-intervention (2019).
  • One hundred reports per cohort analyzed for documentation of marker presence and shape; statistical analysis using logistic regression and chi-squared tests.

Main Results:

  • Documentation of both marker placement and shape significantly improved in the 2019 post-intervention cohort (94.6%) compared to 2014 (30.5%) and 2017 (69.2%).
  • The proportion of biopsies with no marker placed or only marker reported decreased substantially after intervention.
  • Statistical analysis confirmed a significant increase in complete marker and shape documentation in the structured reporting cohort (P < 0.05).

Conclusions:

  • Structured reporting effectively enhances the documentation of breast biopsy markers and their characteristics.
  • This improved documentation may lead to a reduction in medical errors, such as wrong-site surgery.
  • The intervention demonstrates the value of structured reporting in improving procedural safety and diagnostic accuracy.