clinical document

clinical document

A document of clinical observations and services, which, if electronic,  should have the following characteristics: persistence, stewardship, potential for authentication, wholeness and human readability.
References in periodicals archive ?
Gehrig, "Neuroendocrine tumors of the gynecologic tract: a Society of Gynecologic Oncology (SGO) clinical document," Gynecologic Oncology, vol.
East Lansing, MI, November 05, 2016 --(PR.com)-- Michigan Health Information Network Shared Services (MiHIN) maintains its position as a leader in data exchange with efforts of Clinical Document Architecture (CDA) national experts, openAirWare.
He added that while people talk a lot about document standards such as the Health Level Seven International (HL7) standard, as well as complete, widely accepted document formats, such as continuity of care documents (CCDs) and the HL7 consolidated clinical document architectures (C-CDAs), the problem is that while a human who is looking at the document can find something with relative ease, getting it from an electronic medical record (EMR) via XML format can be "an impossible task" as it can't "screen-scrape" the information out of free text-based areas in a CCD.
The solution is intended to help in Direct Clinical Document Architecture Automation of reporting to the Centres for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Kno2 delivers secure, standards-based clinical document exchange to the entire continuum, including emergency medical services (EMS), long-term and post-acute care (LTPAC) providers, home health and behavioral health.
Regarding the general nature of applied de-identification methods, the majority of the systems used only one or two specific clinical document types (pathology reports, discharge summaries or nursing progress notes) for the evaluation [3, 8, 9, 10], while only a few of them were evaluated on a larger scale, with a more heterogeneous document corpus [11, 12, 13, 14].
Compared to earlier versions, the CCD specified for Stage 2 Meaningful Use is to receive a substantial upgrade in its capabilities, detailed in the recently introduced "Consolidated" Clinical Document Architecture (C-CDA).
This physician-centric approach and physician engagement methodology can also facilitate and coordinate clinical document improvement efforts needed to support core measures, medical necessity, severity of illness, and service-level coding based on best practices and evidence-based medicine using clinical decision support technologies to develop quality clinical content.
We are starting to see a healthy penetration of voice recognition technology into our workflow in healthcare, and we seem to just be at the beginning of a revolution in clinical document capture and enhanced clinical efficiency enabled by speech.
Table 1: Current primary methods clinical document exchange Method Percentage E-mail 52% Web-based 25% Courier 12% Fax 9% * 74% report resending documents to sponsors and CROs at least once or twice, and in some cases, more than five times a week
This seeks to unify the CCR with another existing standard known as the HL7 Clinical Document Architecture, or CDA.
A pathology report is a clinical document and should have all of the dimensions of a clinical document (author, date/time, patient ID, etc).

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