作者
S Trent Rosenbloom, Joshua C Denny, Hua Xu, Nancy Lorenzi, William W Stead, Kevin B Johnson
发表日期
2011/3/1
期刊
Journal of the American Medical Informatics Association
卷号
18
期号
2
页码范围
181-186
出版商
BMJ Publishing Group Ltd
简介
Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different factors when writing clinical notes, such as narrative expressivity, amenability to the existing workflow, and usability. The authors explore the tension between expressivity and structured clinical documentation, review methods for obtaining reusable data from clinical notes, and recommend that healthcare providers be able to choose how to document patient care based on workflow and note content needs …
引用总数
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学术搜索中的文章
ST Rosenbloom, JC Denny, H Xu, N Lorenzi… - Journal of the American Medical Informatics …, 2011