title: An electronic health record based on structured narrative.
abstract: OBJECTIVE
  To develop an electronic health record that facilitates rapid capture of detailed narrative observations from clinicians, with partial structuring of narrative information for integration and reuse.
  
  
  METHODS
  We propose a design in which unstructured text and coded data are fused into a single model called structured narrative. Each major clinical event (e.g., encounter or procedure) is represented as a document that is marked up to identify gross structure (sections, fields, paragraphs, lists) as well as fine structure within sentences (concepts, modifiers, relationships). Marked up items are associated with standardized codes that enable linkage to other events, as well as efficient reuse of information, which can speed up data entry by clinicians. Natural language processing is used to identify fine structure, which can reduce the need for form-based entry.
  
  
  RESULTS
  The model is validated through an example of use by a clinician, with discussion of relevant aspects of the user interface, data structures and processing rules.
  
  
  CONCLUSIONS
  The proposed model represents all patient information as documents with standardized gross structure (templates). Clinicians enter their data as free text, which is coded by natural language processing in real time making it immediately usable for other computation, such as alerts or critiques. In addition, the narrative data annotates and augments structured data with temporal relations, severity and degree modifiers, causal connections, clinical explanations and rationale.
  
  
  CONCLUSIONS
  Structured narrative has potential to facilitate capture of data directly from clinicians by allowing freedom of expression, giving immediate feedback, supporting reuse of clinical information and structuring data for subsequent processing, such as quality assurance and clinical research.
authors.affiliation: Department of Biomedical Informatics, Columbia University, New York, NY, USA. sbj2@columbia.edu
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Johnson
authors.forename: Suzanne
authors.initials: S
authors.lastname: Bakken
authors.forename: Daniel
authors.initials: D
authors.lastname: Dine
authors.forename: Sookyung
authors.initials: S
authors.lastname: Hyun
authors.forename: Eneida
authors.initials: E
authors.lastname: Mendonça
authors.forename: Frances
authors.initials: F
authors.lastname: Morrison
authors.forename: Tiffani
authors.initials: T
authors.lastname: Bright
authors.forename: Tielman
authors.initials: T
authors.lastname: Van Vleck
authors.forename: Jesse
authors.initials: J
authors.lastname: Wrenn
authors.forename: Peter
authors.initials: P
authors.lastname: Stetson
mesh_terms: D004282:Documentation; D006801:Humans; D016247:Information Storage and Retrieval / Q000379:methods; D008487:Medical History Taking; D016347:Medical Records Systems, Computerized; D009323:Natural Language Processing; D012984:Software; D018511:Systems Integration; D014584:User-Computer Interface; D018875:Vocabulary, Controlled