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Appl Clin Inform 2010; 01(03): 232-243
DOI: 10.4338/ACI-2010-03-RA-0019
DOI: 10.4338/ACI-2010-03-RA-0019
Research Article
Generating Clinical Notes for Electronic Health Record Systems
Weitere Informationen
Publikationsverlauf
received:
13. März 2009
accepted:
29. Juni 2010
Publikationsdatum:
16. Dezember 2017 (online)
Summary
Clinical notes summarize interactions that occur between patients and healthcare providers. With adoption of electronic health record (EHR) and computer-based documentation (CBD) systems, there is a growing emphasis on structuring clinical notes to support reusing data for subsequent tasks. However, clinical documentation remains one of the most challenging areas for EHR system development and adoption. The current manuscript describes the Vanderbilt experience with implementing clinical documentation with an EHR system. Based on their experience rolling out an EHR system that supports multiple methods for clinical documentation, the authors recommend that documentation method selection be made on the basis of clinical workflow, note content standards and usability considerations, rather than on a theoretical need for structured data.
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