Jove
Visualize
联系我们
JoVE
x logofacebook logolinkedin logoyoutube logo
关于 JoVE
概览领导团队博客JoVE 帮助中心
作者
出版流程编辑委员会范围与政策同行评审常见问题投稿
图书馆员
用户评价订阅访问资源图书馆顾问委员会常见问题
研究
JoVE JournalMethods CollectionsJoVE Encyclopedia of Experiments存档
教育
JoVE CoreJoVE BusinessJoVE Science EducationJoVE Lab Manual教师资源中心教师网站
使用条款与条件
隐私政策
政策

相关概念视频

Documentation in Long-Term and Home Healthcare Setting01:29

Documentation in Long-Term and Home Healthcare Setting

876
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
876
Methods of Documentation V: CBE01:23

Methods of Documentation V: CBE

891
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...
891
Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

2.0K
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...
2.0K
Methods of Documentation II: POMR01:26

Methods of Documentation II: POMR

929
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.
929
Methods of Documentation VII: EMR01:30

Methods of Documentation VII: EMR

828
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...
828
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

1.0K
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.
1.0K

您也可能阅读

相关文章

通过共同作者、期刊和引用图与本文相关的文章。

排序
Same author

Defining Success and Failure In Prosthetic Joint Infections: A Meta-epidemiologic Study Toward A Core Outcome Set.

Open forum infectious diseases·2026
Same author

Assessment of psychological and physiological responses to auditory and visual stimuli during recovery from acute stress induction.

Physiology international·2026
Same author

Occupational distress factors associated with suicidal ideation among physicians and comparison with other US workers.

Academic medicine : journal of the Association of American Medical Colleges·2026
Same author

A systematic review supporting the Endocrine Society clinical practice guidelines on central precocious puberty.

The Journal of clinical endocrinology and metabolism·2026
Same author

Determinants of Patient-Reported Experience After Interhospital Transfer Within an Integrated Health System.

Journal for healthcare quality : official publication of the National Association for Healthcare Quality·2026
Same author

Crisis-Related Self-Reported symptoms of posttraumatic stress disorder in graduate medical education trainees: Results from a Multi-Institutional study.

Academic medicine : journal of the Association of American Medical Colleges·2026

相关实验视频

Updated: Jun 18, 2025

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

8.3K

衡量医疗保健中的文档负担

M Hassan Murad1, Brianna E Vaa Stelling2, Colin P West3

  • 1Mayo Clinic Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN, USA. Murad.mohammad@mayo.edu.

Journal of general internal medicine
|July 29, 2024
PubMed
概括

医疗保健文档负担的措施丰富,但往往是单维的,缺乏有效性. 需要采取新的措施来捕捉不同的临床背景,并为专业倦怠的干预提供信息.

关键词:
燃烧症是什么?燃烧症是什么?燃烧症是什么?文件的负担 文件的负担电子健康记录 电子健康记录医疗保健专业人员的医疗保健专业人员满意度 满足感 满足感系统性审查 系统性审查

更多相关视频

Author Spotlight: Quantifying Pain Experience – An Illustrative Approach Using the Pain Body Diagram
09:00

Author Spotlight: Quantifying Pain Experience – An Illustrative Approach Using the Pain Body Diagram

Published on: July 7, 2023

3.5K
Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients
03:47

Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients

Published on: July 12, 2024

753

相关实验视频

Last Updated: Jun 18, 2025

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

8.3K
Author Spotlight: Quantifying Pain Experience – An Illustrative Approach Using the Pain Body Diagram
09:00

Author Spotlight: Quantifying Pain Experience – An Illustrative Approach Using the Pain Body Diagram

Published on: July 7, 2023

3.5K
Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients
03:47

Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients

Published on: July 12, 2024

753

科学领域:

  • 医疗信息学 医疗信息学
  • 医疗保健管理的管理
  • 医疗文件 医疗文件

背景情况:

  • 电子健康记录 (EHR) 的广泛采用增加了医疗保健专业人员的文档负担.
  • 这种负担是影响工作经验和导致倦怠的重要因素.

研究的目的:

  • 系统地审查和描述现有的文件负担措施.
  • 识别当前测量方法中的差距.

主要方法:

  • 在多个数据库 (MEDLINE,Embase,Scopus) 和2010-2023年灰色文献中进行了全面的文献搜索.
  • 与关键信息人进行的讨论也得到了整合.
  • 用叙事和主题方法合成数据.

主要成果:

  • 确定了135篇关于文档负担措施的文章,分为11种类型 (例如,电子记录时间,收件箱管理,下班时间).
  • 电子病历使用日志是最常见的数据来源;直接跟踪不常见.
  • 措施往往缺乏强有力的有效性证据,并且在捕捉各种领域方面受到限制,医生倦怠是突出的焦点.

结论:

  • 虽然存在许多措施,但它们经常是单维的,缺乏全面的有效性.
  • 迫切需要制定反映不同临床背景的新措施.
  • 改进措施对于支持未来的干预措施来减轻文档负担和倦怠至关重要.