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Methods of Documentation I: Source-Oriented Records01:18

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Source-oriented records, or SOR, are medical record-keeping organized by the data source. The SOR system was first developed in the mid-1900s to organize the growing patient data in hospitals and other healthcare facilities.
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A structure is defined as a system of interconnected members designed to support or transfer forces and successfully withstand the loads acting on them. The internal forces of a structure can be determined by decomposing the structure and analyzing the free-body diagrams of the individual members or of a combination of members. This helps in understanding the structural elements' behavior and ensuring that the structure is stable and can withstand the subjected loads.
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Analyzing Operative Note Structure in Development of a Section Header Resource.

Genevieve B Melton1, Yan Wang2, Elliot Arsoniadis1

  • 1Department of Surgery, University of Minnesota, Minneapolis, MN, USA.

Studies in Health Technology and Informatics
|August 12, 2015
PubMed
Summary
This summary is machine-generated.

Standardizing operative note sections using HL7-ON DSTU and LOINC improves data mapping. This enhances clinical documentation interoperability and natural language processing of surgical procedure details.

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Area of Science:

  • Medical Informatics
  • Clinical Documentation Standards

Background:

  • Operative notes are crucial for documenting surgical procedures.
  • Standardizing section headers in operative notes is essential for data consistency and analysis.

Purpose of the Study:

  • To evaluate the coverage of operative note section headers by the HL7 Implementation Guide for Clinical Document Architecture Release 2.0 Operative Note Draft Standard for Trial Use (HL7-ON DSTU) Release 1.
  • To assess the added value of Logical Observation Identifiers Names and Codes (LOINC®) section names in mapping operative note headers.

Main Methods:

  • Analysis of 384 unique section headers from 362,311 operative notes.
  • Evaluation of coverage using HL7-ON DSTU alone and in combination with LOINC® section names.
  • Assessment of variations in section headers, including synonyms, formatting, and word forms.

Main Results:

  • HL7-ON DSTU alone covered 66% of unique section headers (93% of instances).
  • HL7-ON DSTU combined with LOINC® section names covered 79% of unique headers (98% of instances).
  • Identified significant variations in section headers, such as synonyms and formatting inconsistencies.

Conclusions:

  • HL7-ON DSTU and LOINC® provide substantial coverage for operative note section headers.
  • Effective section mapping is vital for clinical note interoperability and natural language processing applications.
  • A publicly available operative note section resource has been developed to support these efforts.