Structured documentation.
Structured documentation is a concept-oriented method of capturing clinical information that can be shared readily through automated systems. Standards are evolving for controlled vocabularies that are applicable to various aspects of clinical medicine. Vocabulary expressiveness and the significant preparatory work needed to use structured terms are hindrances to the rapid acceptance of these tools; however, the benefits of increased efficiencies, data sharing, and automated triggers may outweigh the cost of these hindrances. Understanding the basic principles of structured documentation and defining the use of the structured data within a practice allows an organization to select a tool that most closely fits its needs.
Zinder
Daniel J
DJ
Medical Corps, United States Navy, 22nd Street North, Arlington, VA 22205, USA. daniel.zinder@verizon.net
D004282:Documentation; D006801:Humans; D016347:Medical Records Systems, Computerized; D039061:Systematized Nomenclature of Medicine; D018875:Vocabulary, Controlled