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Appl Clin Inform 2010; 01(03): 232-243
DOI: 10.4338/ACI-2010-03-RA-0019
Research Article
Schattauer GmbH

Generating Clinical Notes for Electronic Health Record Systems

S.T. Rosenbloom
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
2   Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN
,
W.W. Stead
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
,
J.C. Denny
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
,
D. Giuse
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
,
N.M. Lorenzi
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
,
S.H. Brown
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
2   Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, TN
,
K.B. Johnson
1   Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
› Author Affiliations
Further Information

Publication History

received: 13 March 2009

accepted: 29 June 2010

Publication Date:
16 December 2017 (online)

Also available at
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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.

Keywords

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

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