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

1.4K
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
1.4K
Methods of Documentation III: PIE01:21

Methods of Documentation III: PIE

2.0K
Problem-intervention-evaluation (PIE) is a systematic approach to documentation used in healthcare settings for clinical decision-making and patient care planning. It is a structured approach to organizing patient data based on problems, interventions, and evaluations. Here's a breakdown of its key features and considerations:
2.0K
Methods of Documentation II: POMR01:26

Methods of Documentation II: POMR

1.3K
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.
1.3K
Introduction to Documentation and Reporting01:20

Introduction to Documentation and Reporting

2.8K
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...
2.8K
Methods of Documentation VI: Case Management Model01:15

Methods of Documentation VI: Case Management Model

837
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...
837
Guidelines for Nursing Documentation I01:30

Guidelines for Nursing Documentation I

1.7K
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.
1.7K

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

Optimizing Bispecific Antibody Expression via Multi-Omics Analysis and Vector Redesign.

Biotechnology and bioengineering·2026
Same author

Development and implementation of a pre-clerkship value-added health systems science program: the value-added for inpatients by students and interdisciplinary teams consult service.

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

A Novel Anticoagulation Strategy for High-Volume Plasma Exchange in Pediatric Patients With Acute Liver Failure.

Pediatric transplantation·2025
Same author

Development of the TrendBurden Survey: Assessing Perceived Documentation Burden among Health Professionals in the United States.

Applied clinical informatics·2025
Same author

Correction: A common longitudinal intensive care unit data format (CLIF) for critical illness research.

Intensive care medicine·2025
Same author

A common longitudinal intensive care unit data format (CLIF) for critical illness research.

Intensive care medicine·2025

相关实验视频

Updated: Jan 8, 2026

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
08:13

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

Published on: January 20, 2019

7.0K

使用小儿自动化文档辅助工具改善提供者文档.

Kevin D Smith1, Riley Boland2, Matthew Cerasale3

  • 1Department of Pediatrics, Sections of Pediatric Critical Care and Biomedical Informatics, Biological Sciences Division, University of Chicago, Chicago, Illinois, United States.

Applied clinical informatics
|December 18, 2025
PubMed
概括
此摘要是机器生成的。

自动化文档工具可以通过减少临床文档完整性 (CDI) 编码查询来改善儿科护理. 这项研究表明,实时EHR系统显著减少了查询,提高了提供商的效率.

更多相关视频

Author Spotlight: Improving Radiation Therapy Access with Radiation Planning Assistant
05:18

Author Spotlight: Improving Radiation Therapy Access with Radiation Planning Assistant

Published on: October 6, 2023

1.8K
Measuring the Functional Abilities of Children Aged 3-6 Years Old with Observational Methods and Computer Tools
11:29

Measuring the Functional Abilities of Children Aged 3-6 Years Old with Observational Methods and Computer Tools

Published on: June 20, 2020

9.6K

相关实验视频

Last Updated: Jan 8, 2026

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
08:13

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

Published on: January 20, 2019

7.0K
Author Spotlight: Improving Radiation Therapy Access with Radiation Planning Assistant
05:18

Author Spotlight: Improving Radiation Therapy Access with Radiation Planning Assistant

Published on: October 6, 2023

1.8K
Measuring the Functional Abilities of Children Aged 3-6 Years Old with Observational Methods and Computer Tools
11:29

Measuring the Functional Abilities of Children Aged 3-6 Years Old with Observational Methods and Computer Tools

Published on: June 20, 2020

9.6K

科学领域:

  • 医疗信息学 医疗信息学
  • 儿科医院医药 儿科医院医药
  • 改善临床文档的改善

背景情况:

  • 电子健康记录 (EHR) 对于临床文档完整性 (CDI) 的工具在儿科护理中并不成熟.
  • 提高文档准确性和效率对于儿科住院患者提供者来说至关重要.

研究的目的:

  • 适应和实施一个实时的,自动化文档辅助工具 (AutoDx),用于儿科.
  • 减少临床文档完整性 (CDI) 编码查询,并改善儿科住院医疗服务提供者对实践的感知方便性.

主要方法:

  • 在一个城市的学术儿科医院调整和实施了AutoDx工具,并使用了儿科特定的逻辑规则.
  • 在5个月的实施期间评估了针对性诊断的每1000次出院的CDI查询的主要结果.
  • 评估二次结果,包括提供者调查的实践便利性和工具采用.

主要成果:

  • 目标CDI查询的总比率在实施后下降了58% (每1000次排放中从80.7到33.9;p < 0.001).
  • 间断时间序列分析显示,编码查询立即减少45.5% (p = 0.028),而非目标诊断没有变化.
  • 工具的采用量稳步增加,46%的提供者同意该工具提高了提供优质护理的便利性.

结论:

  • 实时自动化文档支持工具可以在儿科住院患者环境中显著减少CDI编码查询.
  • 尽管存在"任务替代"效应,但AutoDx工具增强了人们对实践的感知方便性,证明了针对性EHR干预在儿科中的价值.