Supporting CMT and user customization in Clinical Documentation templates.
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.
Whipple
Nancy Nasuti
NN
Information Systems, Partners HealthCare System, Boston, MA, USA.
Palchuk
Matvey B
MB
Olsha-Yehiav
Maya
M
Li
Qi
Q
Middleton
Blackford
B
D008498:Medical Record Linkage / Q000379:methods*; D016347:Medical Records Systems, Computerized; D018511:Systems Integration; D018875:Vocabulary, Controlled