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Methods Inf Med 1995; 34(01/02): 57-67
DOI: 10.1055/s-0038-1634580
Original article
Schattauer GmbH

Naming Notes: Transitions from Free Text to Structured Entry

J. Gregory
1   Department of Communication, University of California at San Diego, La Jolla CA
4   Institute for Research on Learning (IRL), Palo Alto CA, USA
,
J. E. Mattison
2   Clinical Information Systems, Kaiser Permanente Medical Group, Southern California Region, Pasadena CA
3   University of California at San Diego, School of Medicine, La Jolla CA
,
C. Linde
4   Institute for Research on Learning (IRL), Palo Alto CA, USA
› Author AffiliationsThe EMR Project is sponsored by the Southern California Region of Kaiser Permanente.
Further Information

Publication History

Publication Date:
09 February 2018 (online)

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Abstract:

To practice medicine in the near future, health care providers in the USA need an information infrastructure they do not yet have. We offer a contribution from social science research to discussions of current medical records practices and how health care activity systems may be transformed by the advent of electronic health records. The goal of the paper is to set forth a framework that connects over-arching questions concerning medical informatics systems development with the practical, cultural and conceptual issues involved in transitions from handwritten and other free text documentation to structured entry of medical records to build patient profiles. The research is broadly framed by an interest in how reciprocal modifications of the design and use of an electronic health record are negotiated in an iterative prototyping project. It is conducted as part of a complex multi-disciplinary research and development effort to create an electronic health record prototype for use in the integrated health care delivery environment of the Southern California Kaiser Permanente Medical Care Program.

Keywords:

Electronic Health Records - Electronic Medical Records - Computer-based Patient Records - Medical Vocabulary - Medical Practice - Diagnostic Codes
 

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