Implementing an interface terminology for structured clinical documentation

Implementing ICD-10: enhancing clinical documentation.

Usability of structured documentation

Semantic Features of an Enterprise Interface Terminology for SNOMED RT

OBJECTIVE To evaluate the utility of SNOMED RT in support of a natural language interface for encoding of clinical assessments. METHOD Using a random sample of clinical terms from the UNMC Lexicon, I mapped the terminology into canonical data entries using SNOMED RT. Working from the source term language, I evaluated lexical mapping to the SNOMED term set, and the function of the SNOMED RT se...

An interface terminology for medical imaging ordering purposes

The need for structured data in electronic health records has not been fully addressed by reference terminologies (RT) due to difficulties of use for end-users. Interface terminologies (IT), built for specific usage and users, and linked to RT, may solve this issue. We propose an IT for medical imaging prescription, based on the French nomenclature for procedure (CCAM), and its qualitative eval...

An Analysis of Narrative Nursing Documentation in an Otherwise Structured Intensive Care Clinical Information System

Most structured nursing documentation systems allow the entry of data in a free text narrative format. Narrative data, while sometimes necessary, cannot easily be analyzed or linked to the structured portion of the record. This study examined the characteristics of free text narrative documentation entered in an otherwise structured record utilized in a cardiovascular intensive care unit. The a...