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Related Concept Videos

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 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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Introduction to Documentation and Reporting01:20

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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 II: POMR01:26

Methods of Documentation II: POMR

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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 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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Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

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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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Updated: Jun 18, 2025

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Measuring Documentation Burden in Healthcare.

M Hassan Murad1, Brianna E Vaa Stelling2, Colin P West3

  • 1Mayo Clinic Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA. Murad.mohammad@mayo.edu.

Journal of General Internal Medicine
|July 29, 2024
PubMed
Summary
This summary is machine-generated.

Measures for healthcare documentation burden are plentiful but often one-dimensional and lack validity. New measures are needed to capture diverse clinical contexts and inform interventions for professional burnout.

Keywords:
burnoutdocumentation burdenelectronic health recordhealthcare professionalssatisfactionsystematic review

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Area of Science:

  • Health Informatics
  • Healthcare Management
  • Medical Documentation

Background:

  • The widespread adoption of electronic health records (EHRs) has increased documentation burden for healthcare professionals.
  • This burden is a significant factor affecting work experience and contributing to burnout.

Purpose of the Study:

  • To systematically review and characterize existing measures of documentation burden.
  • To identify gaps in current measurement approaches.

Main Methods:

  • A comprehensive literature search was conducted across multiple databases (MEDLINE, Embase, Scopus) and gray literature from 2010-2023.
  • Discussions with Key Informants were integrated.
  • Data were synthesized using narrative and thematic approaches.

Main Results:

  • 135 articles on documentation burden measures were identified, categorized into 11 types (e.g., EHR time, inbox management, after-hours work).
  • EHR usage logs were the most common data source; direct tracking was uncommon.
  • Measures often lacked robust validity evidence and were limited in capturing diverse domains, with physician burnout being a prominent focus.

Conclusions:

  • While numerous measures exist, they are frequently one-dimensional and lack comprehensive validity.
  • There is an urgent need for developing new measures that reflect diverse clinical contexts.
  • Improved measures are crucial for supporting future interventions to mitigate documentation burden and burnout.