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 [...]
Author(s): Rosenbloom, S Trent, Stead, William W, Denny, Joshua C, Giuse, Dario, Lorenzi, Nancy M, Brown, Steven H, Johnson, Kevin B
DOI: 10.4338/ACI-2010-03-RA-0019