Data from clinical notes: a perspective on the tension between structure and flexible documentation
Rosenbloom S, Denny J, Xu H, Lorenzi N, Stead W, Johnson K. Data from clinical notes: a perspective on the tension between structure and flexible documentation. Journal Of The American Medical Informatics Association 2011, 18: 181-186. PMID: 21233086, PMCID: PMC3116264, DOI: 10.1136/jamia.2010.007237.Peer-Reviewed Original ResearchMeSH KeywordsData MiningDocumentationEfficiency, OrganizationalElectronic Health RecordsForms and Records ControlHumansMedical Records, Problem-OrientedNatural Language ProcessingReference StandardsSystems IntegrationWorkflowConceptsReusable dataElectronic health record system adoptionStructured documentationComputer-based documentation systemsClinical notesClinical documentationStructured dataText processingSystem adoptionRecord systemSuch systemsDocumentation systemWorkflowContent needsProvidersUsabilityDocumentationExpressivitySystemHealthcare providersPatient careDataProcessingMajor goalAdoption