| Transforming clinical dictation into structured notes in an ambulatory care practice. | |
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MedLine Citation:
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PMID: 15360897 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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Structured clinical encounter notes offer many advantages compared to free text notes. However, cost and other issues limit their widespread use. At our institution, the electronic medical record (EMR) used by an Internal Medicine practice was designed years ago to utilize structured data. This paper describes a technique to improve the process by which structured notes are dictated and transcribed. We outsourced transcription services and then passed the files through parsing software to structure the data to the granularity required for our database. Software was built to handle all aspects of the process including file validation, parsing, and review. During our pilot project, more than 10,000 notes were parsed, reviewed and uploaded into the EMR. |
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Authors:
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Michael Ollendieck; Henry Chueh |
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Publication Detail:
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Type: Journal Article; Research Support, N.I.H., Extramural; Research Support, U.S. Gov't, P.H.S. |
Journal Detail:
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Title: Studies in health technology and informatics Volume: 107 ISSN: 0926-9630 ISO Abbreviation: Stud Health Technol Inform Publication Date: 2004 |
Date Detail:
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Created Date: 2004-09-13 Completed Date: 2005-06-07 Revised Date: 2008-07-10 |
Medline Journal Info:
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Nlm Unique ID: 9214582 Medline TA: Stud Health Technol Inform Country: Netherlands |
Other Details:
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Languages: eng Pagination: 668-72 Citation Subset: IM |
Affiliation:
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Laboratory of Computer Science, Massachusetts General Hospital, Boston, MA, USA. |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Ambulatory Care Humans Information Storage and Retrieval / methods* Internal Medicine Medical Records Systems, Computerized* / economics Pilot Projects Programming Languages Software* Software Design |
| Grant Support | |
ID/Acronym/Agency:
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2T15 LM 07092-11/LM/NLM NIH HHS |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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