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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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Détails bibliographiques
Publié dans:AMIA Annu Symp Proc
Auteurs principaux: Colicchio, Tiago K., Dissanayake, Pavithra I., Cimino, James J.
Format: Artigo
Langue:Inglês
Publié: American Medical Informatics Association 2021
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Accès en ligne:https://ncbi.nlm.nih.gov/pmc/articles/PMC8075472/
https://ncbi.nlm.nih.gov/pubmed/33936404
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