Data from clinical notes: a perspective on the tension between structure and flexible documentation

@article{Rosenbloom2011DataFC,
  title={Data from clinical notes: a perspective on the tension between structure and flexible documentation},
  author={S. Trent Rosenbloom and Joshua C. Denny and Hua Xu and Nancy M. Lorenzi and William W. Stead and Kevin B. Johnson},
  journal={Journal of the American Medical Informatics Association : JAMIA},
  year={2011},
  volume={18 2},
  pages={181-6}
}
Clinical documentation is central to patient care. The success of electronic health record system adoption may depend on how well such systems support clinical documentation. A major goal of integrating clinical documentation into electronic heath record systems is to generate reusable data. As a result, there has been an emphasis on deploying computer-based documentation systems that prioritize direct structured documentation. Research has demonstrated that healthcare providers value different… CONTINUE READING
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