The "ambient scribe" tools listening to and summarising your doctor-patient consultations
Related Experiment Videos
These videos have been matched automatically. Contact us if they are not relevant.
These videos have been matched automatically. Contact us if they are not relevant.
Related Experiment Videos
These videos have been matched automatically. Contact us if they are not relevant.
These videos have been matched automatically. Contact us if they are not relevant.
Related Concept Videos
1.1K
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:
...
1.4K
Flowsheets are valuable tools in nursing documentation. They enable healthcare professionals to efficiently record and monitor various patient assessments and measurements in a consolidated format.
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
• Graphic sheets record patient variables such as vital signs (e.g., temperature, blood pressure, pulse rate, respiratory rate) or daily weights.
• This format presents the...
7.6K
Focusing involves centering a conversation on a message's critical elements or concepts. Focusing is valuable if the talk is vague or patients begin to repeat themselves. Sometimes, when patients are asked about their symptoms, they may go off-topic and try to tell their entire life story. Respectfully, the nurse should bring the conversation back into focus.
This therapeutic technique can also be used when a patient brings up pertinent information during a health-related conversation. The...
943
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:
The date and charting column records the date and time of each entry, providing a chronological record of patient activities.
Focus: The focus column includes information about specific patient concerns or issues, such as nursing...
4.6K
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...
862
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.
Database: This section documents crucial medical information...