Literature DB >> 15064293

Experience in implementing inpatient clinical note capture via a provider order entry system.

S Trent Rosenbloom1, Jonathan Grande, Antoine Geissbuhler, Randolph A Miller.   

Abstract

Care providers' adoption of computer-based health-related documentation ("note capture") tools has been limited, even though such tools have the potential to facilitate information gathering and to promote efficiency of clinical charting. The authors have developed and deployed a computerized note-capture tool that has been made available to end users through a care provider order entry (CPOE) system already in wide use at Vanderbilt. Overall note-capture tool usage between January 1, 1999, and December 31, 2001, increased substantially, both in the number of users and in their frequency of use. This case report is provided as an example of how an existing care provider order entry environment can facilitate clinical end-user adoption of a computer-assisted documentation tool-a concept that may seem counterintuitive to some.

Mesh:

Year:  2004        PMID: 15064293      PMCID: PMC436080          DOI: 10.1197/jamia.M1461

Source DB:  PubMed          Journal:  J Am Med Inform Assoc        ISSN: 1067-5027            Impact factor:   4.497


  51 in total

1.  Standard method for describing an electronic patient record template: application of XML to share domain knowledge.

Authors:  S Yamazaki; Y Satomura
Journal:  Methods Inf Med       Date:  2000-03       Impact factor: 2.176

2.  Clictate: a computer-based documentation tool for guideline-based care.

Authors:  Kevin B Johnson; John Cowan
Journal:  J Med Syst       Date:  2002-02       Impact factor: 4.460

3.  Derivation and evaluation of a document-naming nomenclature.

Authors:  S H Brown; M Lincoln; S Hardenbrook; O N Petukhova; S T Rosenbloom; P Carpenter; P Elkin
Journal:  J Am Med Inform Assoc       Date:  2001 Jul-Aug       Impact factor: 4.497

4.  Usability evaluation of the progress note construction set.

Authors:  S H Brown; S Hardenbrook; L Herrick; J St Onge; K Bailey; P L Elkin
Journal:  Proc AMIA Symp       Date:  2001

5.  A diffusion of innovations model of physician order entry.

Authors:  J S Ash; J Lyman; J Carpenter; L Fournier
Journal:  Proc AMIA Symp       Date:  2001

6.  Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department.

Authors:  K A Marill; E S Gauharou; B K Nelson; M A Peterson; R L Curtis; M R Gonzalez
Journal:  Ann Emerg Med       Date:  1999-05       Impact factor: 5.721

7.  Implementation of clinical guidelines using a computer charting system. Effect on the initial care of health care workers exposed to body fluids.

Authors:  D L Schriger; L J Baraff; W H Rogers; S Cretin
Journal:  JAMA       Date:  1997-11-19       Impact factor: 56.272

8.  Use of computer-based records, completeness of documentation, and appropriateness of documented clinical decisions.

Authors:  P C Tang; M P LaRosa; S M Gorden
Journal:  J Am Med Inform Assoc       Date:  1999 May-Jun       Impact factor: 4.497

9.  Can history and physical examination be used as markers of quality? An analysis of the initial visit note in musculoskeletal care.

Authors:  D H Solomon; J L Schaffer; J N Katz; J Horsky; E Burdick; E Nadler; D W Bates
Journal:  Med Care       Date:  2000-04       Impact factor: 2.983

10.  The computerized notation system: a portable, self-contained system for entry of physicians' and nurses' notes.

Authors:  S R Ash; S L Mertz; D K Ulrich
Journal:  J Clin Eng       Date:  1983 Apr-Jun
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  20 in total

1.  Generating Clinical Notes for Electronic Health Record Systems.

Authors:  S Trent Rosenbloom; William W Stead; Joshua C Denny; Dario Giuse; Nancy M Lorenzi; Steven H Brown; Kevin B Johnson
Journal:  Appl Clin Inform       Date:  2010-01-01       Impact factor: 2.342

2.  Information retrieval performance of probabilistically generated, problem-specific computerized provider order entry pick-lists: a pilot study.

Authors:  Adam S Rothschild; Harold P Lehmann
Journal:  J Am Med Inform Assoc       Date:  2005-01-31       Impact factor: 4.497

3.  Managing the life cycle of electronic clinical documents.

Authors:  Thomas H Payne; Gail Graham
Journal:  J Am Med Inform Assoc       Date:  2006-04-18       Impact factor: 4.497

4.  The transition to electronic documentation on a teaching hospital medical service.

Authors:  Thomas H Payne; Monica Perkins; Robert Kalus; Dom Reilly
Journal:  AMIA Annu Symp Proc       Date:  2006

5.  A regional health information exchange: architecture and implementation.

Authors:  Mark E Frisse; Janet K King; Will B Rice; Lianhong Tang; Jameson P Porter; Timothy A Coffman; Michael Assink; Kevin Yang; Monroe Wesley; Rodney L Holmes; Cynthia Gadd; Kevin B Johnson; Vicki Y Estrin
Journal:  AMIA Annu Symp Proc       Date:  2008-11-06

6.  Development and evaluation of a clinical note section header terminology.

Authors:  Joshua C Denny; Randolph A Miller; Kevin B Johnson; Anderson Spickard
Journal:  AMIA Annu Symp Proc       Date:  2008-11-06

7.  Preliminary development of the physician documentation quality instrument.

Authors:  Peter D Stetson; Frances P Morrison; Suzanne Bakken; Stephen B Johnson
Journal:  J Am Med Inform Assoc       Date:  2008-04-24       Impact factor: 4.497

8.  Evaluation of a method to identify and categorize section headers in clinical documents.

Authors:  Joshua C Denny; Anderson Spickard; Kevin B Johnson; Neeraja B Peterson; Josh F Peterson; Randolph A Miller
Journal:  J Am Med Inform Assoc       Date:  2009-08-28       Impact factor: 4.497

9.  Data from clinical notes: a perspective on the tension between structure and flexible documentation.

Authors:  S Trent Rosenbloom; Joshua C Denny; Hua Xu; Nancy Lorenzi; William W Stead; Kevin B Johnson
Journal:  J Am Med Inform Assoc       Date:  2011-01-12       Impact factor: 4.497

Review 10.  A knowledge-based taxonomy of critical factors for adopting electronic health record systems by physicians: a systematic literature review.

Authors:  Víctor H Castillo; Ana I Martínez-García; J R G Pulido
Journal:  BMC Med Inform Decis Mak       Date:  2010-10-15       Impact factor: 2.796

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