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The anatomy of clinical documentation: an assessment and classification of narrative note sections format and content

Introduction. We systematically analyzed the most commonly used narrative note formats and content found in primary and specialty care visit notes to inform future research and electronic health record (EHR) development. Methods. We extracted data from the history of present illness (HPI) and impres...

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Bibliografiske detaljer
Udgivet i:AMIA Annu Symp Proc
Main Authors: Colicchio, Tiago K., Dissanayake, Pavithra I., Cimino, James J.
Format: Artigo
Sprog:Inglês
Udgivet: American Medical Informatics Association 2021
Fag:
Online adgang:https://ncbi.nlm.nih.gov/pmc/articles/PMC8075472/
https://ncbi.nlm.nih.gov/pubmed/33936404
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