Related Experiment Video
Updated: Aug 14, 2026
09:00
TBase - an Integrated Electronic Health Record and Research Database for Kidney Transplant Recipients
Published on: April 13, 2021
Transition to a computer-based record using scannable, structured encounter forms
R N Shiffman1, C A Brandt, B G Freeman
1Department of Pediatrics, Yale University School of Medicine, New Haven, Conn., USA. richard.shiffman@yale.edu
Archives of Pediatrics & Adolescent Medicine
|December 31, 1997
Summary
Structured documentation systems improve pediatric health maintenance records, documenting more developmental and guidance items. This system enhances electronic medical records and user satisfaction, easing the transition to digital patient records.
Area of Science:
- Pediatric Health Maintenance
- Electronic Medical Records
- Clinical Documentation Systems
Background:
- Traditional paper-based documentation systems can lead to incomplete records.
- Transitioning to electronic medical records (EMR) presents challenges in data quality and user adoption.
- Improving documentation quality in pediatric health maintenance is crucial for comprehensive patient care.
Purpose of the Study:
- To assess the documentation quality of a structured documentation system for pediatric health maintenance encounters.
- To evaluate user satisfaction with a system using scanned paper forms for EMR generation.
- To determine the long-term effectiveness of structured documentation in maintaining high-quality records.
Main Methods:
- Retrospective review comparing structured (ST) and unstructured records.
- User satisfaction assessment via questionnaires.
- Analysis of EMR data one year post-implementation to evaluate persistence of effects.
Main Results:
- Structured records documented significantly more data elements, including developmental items (11.5 vs 4.8) and anticipatory guidance (8.3 vs 2.5).
- Ninety percent of users preferred the structured system.
- High documentation thoroughness persisted one year after system adoption.
Conclusions:
- Structured, scannable encounter forms enhance the quality of pediatric health maintenance documentation.
- This system is well-accepted by healthcare providers, facilitating EMR transition.
- Structured documentation offers an effective solution for improving clinical record-keeping.
Related Concept Videos
01:24Data Reporting and Recording
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...
01:18Methods of Documentation I: Source-Oriented Records
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:
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:
01:26Methods of Documentation IV: Focus Charting
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:
It typically involves three columns for recording information:
01:30Methods 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,...
01:18Guidelines and Strategies for Safe Computer Charting
The guidelines and strategies provided by the American Nurses Association (ANA) and the Canadian Nurses Association (CNA) offer essential principles for ensuring safe and secure computer charting systems in healthcare settings. Let's break down each recommendation:
Maintain Confidentiality and Security:
Maintain Confidentiality and Security:
01:31Discharge Summary Forms
The discharge summary is crucial as it enables a smooth transition from a healthcare facility to a patient's home or another care setting. This critical document facilitates seamless continuity of care, ensuring patients receive the necessary support and attention.
Here's a detailed look at the key components and guidelines for preparing a discharge summary:
Here's a detailed look at the key components and guidelines for preparing a discharge summary: