Jove
Visualize
Contact Us
JoVE
x logofacebook logolinkedin logoyoutube logo
ABOUT JoVE
OverviewLeadershipBlogJoVE Help Center
AUTHORS
Publishing ProcessEditorial BoardScope & PoliciesPeer ReviewFAQSubmit
LIBRARIANS
TestimonialsSubscriptionsAccessResourcesLibrary Advisory BoardFAQ
RESEARCH
JoVE JournalMethods CollectionsJoVE Encyclopedia of ExperimentsArchive
EDUCATION
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab ManualFaculty Resource CenterFaculty Site
Terms & Conditions of Use
Privacy Policy
Policies

Related Concept Videos

Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

768
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...
768
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

932
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.
932
Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

805
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...
805
Documentation of Nursing Diagnosis01:10

Documentation of Nursing Diagnosis

1.2K
The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
In some settings, data-driven computerized decision support systems are in place, allowing for more accurate nursing diagnoses. The database within one of these systems includes diagnostic labels defining characteristics, activities, and indicators for nursing. A nurse enters...
1.2K
Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

1.4K
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...
1.4K
Pharmacovigilance01:19

Pharmacovigilance

732
Post-marketing surveillance is a critical component of pharmaceutical regulation, often uncovering unanticipated adverse drug reactions (ADRs) once a drug is widely used over an extended period.
This process, termed pharmacovigilance, aims to detect, evaluate, and minimize harmful effects related to medication use. The data collection for pharmacovigilance depends on spontaneous reporting systems, where healthcare professionals or patients voluntarily report suspected ADRs.
In some cases, there...
732

You might also read

Related Articles

Articles linked to this work by shared authors, journal, and citation graph.

Sort by
Same author

Medication Safety Self-assessment in Hospital Wards Within A Regional Health Services System: A Descriptive Follow-up Study.

Journal of patient safety·2026
Same author

Medication safety in family caregiving of older adults: home visits including interviews, observations, and medication reviews.

BMC geriatrics·2026
Same author

Receipt of Medicines Information From the Internet and Other Information Sources Among Adult Medicine Users in Developed Economies, 2010-2025: Systematic Review.

Journal of medical Internet research·2026
Same author

Financial Toxicity Associated with Biological Medicines: A Scoping Review.

Clinical pharmacology and therapeutics·2026
Same author

Facilitators and barriers in using barcode technology to ensure safe medication dispensing, preparation, and administration in a children's hospital: a focus group study for clinical pharmacists.

International journal of clinical pharmacy·2026
Same author

Effects of pharmacist-conducted medication order verification in a hospital setting: a systematic review.

European journal of hospital pharmacy : science and practice·2026

Related Experiment Video

Updated: May 9, 2025

Drug Repurposing Hypothesis Generation Using the "RE:fine Drugs" System
05:10

Drug Repurposing Hypothesis Generation Using the "RE:fine Drugs" System

Published on: December 11, 2016

9.2K

Identifying Medication Review Topics to Be Documented in a Structured Form in Electronic Health Record Systems:

Tanja Lindholm1, Noora Lias1, Kirsi Kvarnström1,2,3

  • 1Clinical Pharmacy Group, Division of Pharmacology and Pharmacotherapy, Faculty of Pharmacy, University of Helsinki, Helsinki, Finland.

Journal of Medical Internet Research
|May 6, 2025
PubMed
Summary

Structured documentation of medication review (MR) results in electronic health records (EHRs) improves data sharing. Key information includes blood pressure, kidney function, and bleeding risk for optimized patient care.

Keywords:
electronic health recordinformation managementmedical informaticsmedication informationmedication reviewpatient informationstructured documentation

More Related Videos

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
08:13

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

Published on: January 20, 2019

6.5K
E-Patient Counseling Trial E-PACO: Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy
06:28

E-Patient Counseling Trial E-PACO: Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

Published on: August 1, 2019

8.2K

Related Experiment Videos

Last Updated: May 9, 2025

Drug Repurposing Hypothesis Generation Using the "RE:fine Drugs" System
05:10

Drug Repurposing Hypothesis Generation Using the "RE:fine Drugs" System

Published on: December 11, 2016

9.2K
Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
08:13

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

Published on: January 20, 2019

6.5K
E-Patient Counseling Trial E-PACO: Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy
06:28

E-Patient Counseling Trial E-PACO: Computer Based Education versus Nurse Counseling for Patients to Prepare for Colonoscopy

Published on: August 1, 2019

8.2K

Area of Science:

  • Health Informatics
  • Clinical Pharmacy
  • Patient Data Management

Background:

  • Electronic health record (EHR) interoperability challenges hinder clinical decision-making and patient data access.
  • Structured documentation of medication-related information, including medication reviews (MRs), is crucial for optimizing medication regimens, particularly in older adults.

Purpose of the Study:

  • To identify essential information from MRs that should be documented in a structured format within EHRs.
  • To establish national and organizational standards for structured documentation of MR outcomes.

Main Methods:

  • A 3-round Delphi consensus survey conducted in 2020 with 41 interprofessional expert panelists (physicians, pharmacists, nurses, information management professionals).
  • Survey based on a comprehensive inventory of international and national MR procedures.
  • Quantitative and qualitative analysis of expert assessments on topics for structured EHR documentation, with an 80% consensus limit.

Main Results:

  • Consensus reached on 97.3% of predetermined topics for structured EHR documentation.
  • Key documented areas include MR process (39 topics), drug-induced symptoms (25), adverse drug effect risks (11), lab results (12), medication adherence (12), and intoxicant use (9).
  • Top-ranked topics for structured documentation: patient's blood pressure, kidney function, and risk of bleeding. MR results should be accessible in national digital repositories and to patients.

Conclusions:

  • Strong interprofessional expert agreement on essential MR results for structured EHR documentation.
  • Standardized documentation and accessibility of MR information are vital for care teams and patients.