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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...

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 settings,...

Documentation in Long-Term and Home Healthcare Setting

Documentation in Long-Term and Home Healthcare Setting

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

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.

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:

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.

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Related Experiment Video

Updated: Jul 4, 2026

Expired CO2 Measurement in Intubated or Spontaneously Breathing Patients from the Emergency Department

Expired CO₂ Measurement in Intubated or Spontaneously Breathing Patients from the Emergency Department

Published on: January 29, 2011

Ambient AI Scribes and Emergency Department Documentation Burden: Retrospective Cohort Study.

Carl Preiksaitis¹, Al'ai Alvarez¹, Maia Winkel¹

¹Department of Emergency Medicine, School of Medicine, Stanford University, Palo Alto, CA, United States.

|July 2, 2026

Summary

Ambient artificial intelligence (AI) scribes significantly reduced on-shift documentation time in the emergency department (ED). This AI tool offers a promising solution to decrease clinician burnout by streamlining clinical documentation.

Keywords:

AI ambient scribes artificial intelligence clinical informatics documentation burden electronic health records emergency medicine physician burnout workflow efficiency

Related Experiment Videos

Last Updated: Jul 4, 2026

Expired CO2 Measurement in Intubated or Spontaneously Breathing Patients from the Emergency Department

Expired CO₂ Measurement in Intubated or Spontaneously Breathing Patients from the Emergency Department

Published on: January 29, 2011

Area of Science:

Medical Informatics
Artificial Intelligence in Healthcare
Emergency Medicine

Background:

Clinician burnout is a critical issue in emergency medicine, largely driven by extensive clinical documentation burdens.
Ambient artificial intelligence (AI) scribes present a potential solution to alleviate this documentation load.
Objective evidence for AI scribe effectiveness in emergency departments (EDs) is limited, with prior studies having short observation periods and low adoption rates.

Purpose of the Study:

To assess the impact of ambient AI scribe utilization on on-shift documentation time within a busy tertiary academic ED.
To analyze this association over a 13-month staged implementation period, considering physician and patient variables.

Main Methods:

A retrospective cohort study was conducted involving 10,344 encounters across 4 ED settings.
The study included 100 attending physicians, excluding encounters with human scribes or multiple attending physicians.
On-shift documentation time was the primary outcome, analyzed using mixed-effects linear models to control for confounding factors.

Main Results:

Ambient AI scribe use correlated with a significant reduction of 72.6 seconds in on-shift documentation time per encounter (P<.001).
The reduction in documentation time was consistent across high-use and low/moderate-use physicians.
A decrease in note character count was observed, alongside a modest increase in after-shift documentation time.

Conclusions:

Ambient AI scribes demonstrated a statistically significant decrease in on-shift documentation time in the ED setting.
The findings suggest potential time savings of approximately 24 minutes per 8-hour shift with widespread AI scribe adoption.
While AI scribes show clinical relevance for reducing documentation burden, individual physician, patient, and workflow factors influence the magnitude of benefit.