title: Supporting CMT and user customization in Clinical Documentation templates.
abstract: Clinical Documentation in the ambulatory care setting must support each clinician's unique workflow and data collection requirements. In addition the documentation system must also be the foundation for interoperability both within and external to the organization. Linking documentation to controlled medical terminologies (CMT) provides data sharing capability and centralized management and quality reporting. Separating codified content from its presentation allows clinicians to create templates and forms that meet these requirements while still ensuring data integrity.
authors.affiliation: Information Systems, Partners HealthCare System, Boston, MA, USA.
authors.forename: Nancy Nasuti
authors.initials: NN
authors.lastname: Whipple
authors.forename: Matvey B
authors.initials: MB
authors.lastname: Palchuk
authors.forename: Maya
authors.initials: M
authors.lastname: Olsha-Yehiav
authors.forename: Qi
authors.initials: Q
authors.lastname: Li
authors.forename: Blackford
authors.initials: B
authors.lastname: Middleton
mesh_terms: D008498:Medical Record Linkage / Q000379:methods*; D016347:Medical Records Systems, Computerized; D018511:Systems Integration; D018875:Vocabulary, Controlled