Zetterberg Carina, Ahlzén Karin, Ericsson Erika, Kron Bengt
Department of Gynecology and Obstetrics, Örebro University Hospital, Örebro County Council, Sweden.
Stud Health Technol Inform. 2012;180:1215-7.
Structured code-based documentation, i.e. templates which restrain the user with predetermined terms/phrases bound to terminologies, offers opportunities for advanced types of retrieval and guides the user in multiple ways; to act in accordance with evidence, for decision support and to achieve adequate documentation for the condition in question. This type of documentation is especially appropriate in health care processes which are nearly the same every time. A template for documentation of the family planning process (abortion) was elaborated at a Swedish hospital. It uses both structured elements and free-text and covers all information needed in the process. The predetermined terms and phrases were bound to SNOMED CT concepts. After the template has been completed, it forms the basis for a customary free-text note in the record. The structured information is also stored in its original form and can be used for different kinds of advanced data retrieval. The documentation is completed during the visit and there is no need for additional secretarial work. The implementation has reduced the total time used for documentation, reporting and follow up and shows that process-oriented structured documentation bound to SNOMED CT improves the documentation, supports advanced retrieval of data and reduces resource utilization.
基于代码的结构化文档，即通过预定义术语/短语与术语表绑定来限制用户的模板，为高级检索类型提供了机会，并以多种方式指导用户；使其依据证据行事，提供决策支持，并为相关病情实现充分的文档记录。这种类型的文档在每次几乎相同的医疗保健流程中尤为适用。瑞典一家医院精心制作了一份计划生育流程（堕胎）的文档模板。它既使用结构化元素，也包含自由文本，涵盖了该流程所需的所有信息。预定义的术语和短语与SNOMED CT概念相关联。模板完成后，它构成了记录中常规自由文本注释的基础。结构化信息也以其原始形式存储，可用于各种高级数据检索。文档在就诊期间完成，无需额外的秘书工作。该实施减少了用于文档记录、报告和随访的总时间，并表明与SNOMED CT绑定的面向流程的结构化文档改善了文档记录，支持高级数据检索并减少了资源利用。
