Generating Clinical Notes for Electronic Health Record Systems

作者：Rosenbloom S T^*; Stead W W; Denny J C; Giuse D; Lorenzi N M; Brown S H; Johnson K B

来源：Applied Clinical Informatics, 2010, 1(3): 232-243.

DOI：10.4338/ACI-2010-03-RA-0019

• Computer based documentation
• electronic health records
• medical informatics applications
• computerized medical records systems
• user-computer interface

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.

• 出版日期2010