Search research articles

ABOUT JoVE

Overview Leadership Blog JoVE Help Center

AUTHORS

Publishing Process Editorial Board Scope & Policies Peer Review FAQ Submit

LIBRARIANS

Testimonials Subscriptions Access Resources Library Advisory Board FAQ

RESEARCH

JoVE Journal Methods Collections JoVE Encyclopedia of Experiments Archive

EDUCATION

JoVE Core JoVE Business JoVE Science Education JoVE Lab Manual Faculty Resource Center Faculty Site

Terms & Conditions of Use

Related Concept Videos

Guidelines for Nursing Documentation II

Guidelines for Nursing Documentation II

Effective documentation is an integral part of nursing practice. Here are some essential guidelines to follow when documenting patient care:
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.

Guidelines for Nursing Documentation I

Guidelines for Nursing Documentation I

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.

Methods of Documentation V: CBE

Methods of Documentation V: CBE

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...

Legal Guidelines for Documentation

Legal Guidelines for Documentation

The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:

Methods of Documentation VII: EMR

Methods of Documentation VII: EMR

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...

Documentation of Nursing Diagnosis

Documentation of Nursing Diagnosis

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...

You might also read

Related Articles

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

Sort by

Same author

Empowering educators: AI literacy as a catalyst for competency-based health information training.

Health information management : journal of the Health Information Management Association of Australia·2026

Same author

Assessing Artificial Intelligence Literacy: What do Health Information Professionals Know about AI?

Advances in health information science and practice·2025

Same author

Impact of the COVID-19 Pandemic on HIM Professionals in a Rural State.

Perspectives in health information management·2022

Same author

STUDENT PERCEPTIONS OF AN UNDERGRADUATE INTERPROFESSIONAL CAPSTONE COURSE INCLUDING HEALTH INFORMATION MANAGEMENT.

Perspectives in health information management·2021

Same author

Transitioning to ICD-10-CM/PCS in the classroom: countdown to 2014.

Journal of AHIMA·2012

Same author

Advancing the academic transition to ICD-10-CM/PCS.

Journal of AHIMA·2010

Search research articles

Related Experiment Video

Updated: Jan 17, 2026

Induction and Clinical Scoring of Chronic-Relapsing Experimental Autoimmune Encephalomyelitis

Induction and Clinical Scoring of Chronic-Relapsing Experimental Autoimmune Encephalomyelitis

Published on: July 4, 2007

Current Challenges in Encephalopathy Documentation and Coding.

Jaime Sand¹, Alba Kuqi²

¹College of Health Sciences Boise State University.

Advances in Health Information Science and Practice

|September 22, 2025

Summary

This summary is machine-generated.

Accurate coding for encephalopathy is challenging due to its varied causes and lack of specific guidelines. Improved documentation and communication are crucial for correct medical coding and reimbursement.

Keywords:

CDI Coding Denials Encephalopathy ICD-10 ICD-10-CM Review

More Related Videos

Author Spotlight: Evaluating the Adjuvant Efficacy and Safety of Angong Niuhuang Pill in Viral Encephalitis Treatment

Author Spotlight: Evaluating the Adjuvant Efficacy and Safety of Angong Niuhuang Pill in Viral Encephalitis Treatment

Published on: April 19, 2024

Hippocampal Neuronal Cultures to Detect and Study New Pathogenic Antibodies Involved in Autoimmune Encephalitis

Hippocampal Neuronal Cultures to Detect and Study New Pathogenic Antibodies Involved in Autoimmune Encephalitis

Published on: June 2, 2022

Related Experiment Videos

Last Updated: Jan 17, 2026

Induction and Clinical Scoring of Chronic-Relapsing Experimental Autoimmune Encephalomyelitis

Induction and Clinical Scoring of Chronic-Relapsing Experimental Autoimmune Encephalomyelitis

Published on: July 4, 2007

Author Spotlight: Evaluating the Adjuvant Efficacy and Safety of Angong Niuhuang Pill in Viral Encephalitis Treatment

Author Spotlight: Evaluating the Adjuvant Efficacy and Safety of Angong Niuhuang Pill in Viral Encephalitis Treatment

Published on: April 19, 2024

Hippocampal Neuronal Cultures to Detect and Study New Pathogenic Antibodies Involved in Autoimmune Encephalitis

Hippocampal Neuronal Cultures to Detect and Study New Pathogenic Antibodies Involved in Autoimmune Encephalitis

Published on: June 2, 2022

Area of Science:

Medical Informatics
Clinical Neurology

Background:

Encephalopathy presents diagnostic and coding complexities in clinical practice.
It is a secondary condition requiring precise etiological identification (e.g., hepatic, hypertensive, metabolic).

Purpose of the Study:

To synthesize challenges in diagnosing and documenting encephalopathy.
To explore the impact of encephalopathy etiologies on coding accuracy and reimbursement.
To highlight the need for standardized practices.

Main Methods:

Literature review of 26 articles and relevant forums.
Synthesis of information on encephalopathy diagnosis, documentation, and coding.

Main Results:

Lack of official coding guidelines for encephalopathy leads to claim denials.
Varied etiologies of encephalopathy complicate accurate ICD-10-CM code assignment.
Effective communication among providers, coders, and specialists is vital.

Conclusions:

Standardized documentation and accurate ICD-10-CM coding are essential for encephalopathy.
Proper querying techniques are necessary to ensure coding integrity and reimbursement.
Clear communication supports accurate patient condition representation.