Rosenbloom S Trent, Stead William W, Denny Joshua C, Giuse Dario, Lorenzi Nancy M, Brown Steven H, Johnson Kevin B
Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN.
Appl Clin Inform. 2010 Jan 1;1(3):232-243. doi: 10.4338/ACI-2010-03-RA-0019.
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.
临床记录总结了患者与医疗服务提供者之间发生的互动。随着电子健康记录（EHR）和基于计算机的文档（CBD）系统的采用，人们越来越强调对临床记录进行结构化，以支持将数据用于后续任务。然而，临床文档仍然是EHR系统开发和采用中最具挑战性的领域之一。当前的手稿描述了范德比尔特大学在使用EHR系统实施临床文档方面的经验。基于他们推出支持多种临床文档方法的EHR系统的经验，作者建议根据临床工作流程、记录内容标准和可用性考虑来选择文档方法，而不是基于对结构化数据的理论需求。
