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

Guidelines for Nursing Documentation II01:26

Guidelines for Nursing Documentation II

1.0K
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.
1.0K
Legal Guidelines for Documentation01:06

Legal Guidelines for Documentation

1.3K
The legal guidelines for nursing documentation are essential for ensuring accurate, professional, and ethical recording of patient care. The guidelines are discussed here:
1.3K
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
Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

559
The case management model is a multidisciplinary approach that involves healthcare professionals from diverse disciplines, such as physicians, nurses, therapists, social workers, and pharmacists, working collaboratively to address the various needs of patients. Each healthcare professional brings unique expertise and perspectives, contributing to a more comprehensive understanding of the patient's condition and tailoring treatment plans accordingly.
For example, a patient with a chronic...
559
Role of Communication in the Nursing Process III: Evaluation and Documentation01:08

Role of Communication in the Nursing Process III: Evaluation and Documentation

1.3K
A successful patient outcome depends mainly on the evaluation stage of the nursing process. Evaluation determines effectiveness by reviewing what was done previously after the completion of nursing interventions. Every time a healthcare professional steps in or administers treatment, they must reassess or evaluate the action to ensure the intended result. During the evaluation phase, there are three probable patient outcomes:
1.3K
Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

1.9K
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...
1.9K

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

Addressing high-utilizers of virtual urgent care through an EHR clinical decision support nudge.

Journal of telemedicine and telecare·2026
Same author

Artificial Intelligence Summarization in the Emergency Department-One Size Does Not Fit All.

JAMA network open·2026
Same author

Pharmacy Interventions on Medication Orders Increase With Emergency Medicine Clinician Time-on-Shift.

Annals of emergency medicine·2026
Same author

Nudging provider adoption of clinical decision support: study protocol for a stepped-wedge cluster randomized, hybrid type III trial of an electronic health record-agnostic pulmonary embolism risk tool.

Implementation science : IS·2026
Same author

Generative artificial intelligence for inpatient documentation summarization: mixed-methods quality assessment and early real-world experience.

Journal of the American Medical Informatics Association : JAMIA·2026
Same author

Artificial intelligence for predicting hospital admissions from the emergency department: a prospective, quasi-experimental study.

Nature communications·2026
Same journal

Smart Dosing, Better Outcomes: An Electronic Medical Record Intervention for Cancer Pain in the Emergency Department.

Journal of the American College of Emergency Physicians open·2026
Same journal

Correction to "Emergency Department Crowding and Diagnostic Safety: An Underrecognized Risk to Clinical Decision Making".

Journal of the American College of Emergency Physicians open·2026
Same journal

Enhancing Care for Critically Ill Patients Boarding in the Emergency Department: A 360° Evaluation of an Emergency Medicine Critical Care Fellow Model.

Journal of the American College of Emergency Physicians open·2026
Same journal

Adolescent Substance Use Screening in the Emergency Department.

Journal of the American College of Emergency Physicians open·2026
Same journal

Miller Fisher Syndrome Should Only be Diagnosed if the Diagnostic Criteria are Met and All Other Differential Diagnoses Have Been Ruled Out.

Journal of the American College of Emergency Physicians open·2026
Same journal

Young Man With Sudden Quadriplegia After Neck Massage.

Journal of the American College of Emergency Physicians open·2026
查看所有相关文章

相关实验视频

Updated: May 25, 2025

A Standardized Approach to Extra-Oral and Intra-Oral Digital Photography
06:49

A Standardized Approach to Extra-Oral and Intra-Oral Digital Photography

Published on: July 22, 2022

7.2K

解决笔记膨胀问题:为有效的临床文档提供解决方案

Nicholas Genes1, Joseph Sills2, Heather A Heaton3

  • 1Department of Emergency Medicine Ronald O. Perelman, NYU Grossman School of Medicine, New York, New York, USA.

Journal of the American College of Emergency Physicians open
|February 27, 2025
PubMed
概括
此摘要是机器生成的。

临床文档或"笔记膨胀"在紧急医疗中是一个日益严重的问题. 本研究讨论了改善医疗笔记清晰度和简洁性的策略,以便更好地做出决策.

关键词:
临床信息学 临床信息学文件 文档 文档 文件 文档电子医疗记录 电子医疗记录退款是为了补偿.

更多相关视频

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
07:50

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

15.7K
Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
14:32

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

Published on: February 16, 2011

23.4K

相关实验视频

Last Updated: May 25, 2025

A Standardized Approach to Extra-Oral and Intra-Oral Digital Photography
06:49

A Standardized Approach to Extra-Oral and Intra-Oral Digital Photography

Published on: July 22, 2022

7.2K
A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
07:50

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

15.7K
Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care
14:32

Using Visual and Narrative Methods to Achieve Fair Process in Clinical Care

Published on: February 16, 2011

23.4K

科学领域:

  • 医疗信息学 医疗信息学
  • 改善临床文档 改善临床文档

背景情况:

  • 美国的临床文档越来越长,越来越难以阅读,被称为"笔记膨胀".
  • 这一问题在紧急医疗中尤其具有挑战性,因为诊断的不确定性很高,需要快速做出决定.
  • 导致笔记膨胀的因素包括计费优化,不当行为风险减轻和电子健康记录 (EHR) 功能.

研究的目的:

  • 讨论改善临床笔记清晰度和简洁性的最佳实践.
  • 探索最近的E/M编码改革对文档实践的影响.
  • 考虑新兴技术 (如生成性人工智能) 在解决笔记膨胀方面的作用.

主要方法:

  • 对临床文档最佳实践的现有证据和专家意见的审查.
  • 分析最近的评估和管理 (E/M) 编码改革的影响.
  • 讨论技术进步及其对医疗文档的潜在影响.

主要成果:

  • 纸币膨胀是由金融,法律和技术因素的交汇驱动的.
  • 电子/机器编码改革旨在简化文档,但面临着不同的实施.
  • 像人工智能这样的新技术为文档提供了潜在的解决方案和新的挑战.

结论:

  • 提高笔记清晰度和简洁性需要一个多方面的方法.
  • 临床领导,电子健康记录供应商和专业组织之间的合作是必不可少的.
  • 持续适应新技术和编码准则是必要的,以打击笔记膨胀.