Predefined headings in a multiprofessional electronic health record system.
Applying multiprofessional electronic health records (EHRs) is expected to improve the quality of patient care and patient safety. Both EHR systems and system users depend on semantic interoperability to function efficiently. A shared clinical terminology comprising unambiguous terms is required for semantic interoperability. Empirical studies of clinical terminology, such as predefined headings, in EHR systems are scarce and limited to one profession or one clinical specialty.
Author(s): Terner, Annika, Lindstedt, Helena, Sonnander, Karin
DOI: 10.1136/amiajnl-2012-000855