Derivation and evaluation of a document-naming nomenclature.
OBJECTIVE
The Computerized Patient Record System is deployed at all 173 Veterans Affairs (VA) medical centers. Providers access clinical notes in the system from a note title menu. Following its implementation at the Nashville VA Medical Center, users expressed dissatisfaction with the time required find notes among hundreds of irregularly structured titles. The authors' objective was to develop a document-naming nomenclature (DNN) that creates informative, structured note titles that improve information access.


METHODS
One thousand ninety-four unique note titles from two VA medical centers were reviewed. A note-naming nomenclature and compositional syntax were derived. Compositional order was determined by user preference survey.


METHODS
The DNN was evaluated by modeling note titles from the Salt Lake City VA Medical Center (n=877), Vanderbilt University Medical Center (n=554), and the Mayo Clinic (n=42). A preliminary usability evaluation was conducted on a structured title display and sorting application.


RESULTS
Classes of note title components were found by inspection. Components describe characteristics of the author, the health care event, and the organizational unit providing care. Terms were taken from VA medical center information systems and national standards. The DNN model accurately described 97 to 99 percent of note titles from the test sites. The DNN term coverage varied, depending on component and site. Users found the DNN title format useful and the DNN-based title sorting and note review application easy to learn and quick to use.


CONCLUSIONS
The DNN accurately models note titles at five medical centers. Preliminary usability data indicate that DNN integration with title parsing and sorting software enhances information access.
Brown
S H
SH
Department of Veterans Affairs, Tennessee Valley Healthcare System, Nashville, Tennessee, USA. steven.brown@med.va.gov
Lincoln
M
M
Hardenbrook
S
S
Petukhova
O N
ON
Rosenbloom
S T
ST
Carpenter
P
P
Elkin
P
P
D000043:Abstracting and Indexing / Q000379:methods*; D006787:Hospitals, Veterans; D006801:Humans; D016247:Information Storage and Retrieval / Q000379:methods; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D013714:Tennessee; D009626:Terminology as Topic; D018875:Vocabulary, Controlled