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A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
Developing an Approach for Aggregating Information From a EHR into a Fully Structured Patient Summary
Patrick Mangesius1, Samrend Saboor2, Thomas Schabetsberger1
1ITH icoserve technology for healthcare GmbH, Innsbruck, Austria.
Background:
Providing healthcare professionals with adequate access to well-filled electronic patient records and health-related information contributes to an improvement of the treatment process. Compared to conventional Electronic Medical Records these EHR systems commonly contain more medical artifacts due to their cross institutional, multipurpose use cases. Physicians and health professionals are therefore concerned about information overflow.
Objectives:
Goal of this paper is to elaborate new concepts for the automated aggregation of a fully-structured patient summary document based on information extracted from documents which are published in large-scale EHRs.
Methods:
The first step was the conduction of semi-structured group interviews with experts and customers. This was followed by a qualitative literature analysis. Consequently technical and medical standards in the field of interoperability were screened.
Results:
The result of this paper is the elaboration of an architectural approach to integrate an automatic patient summary creation into well established workflows of large ehealth projects based on standard IHE XDS infrastructures, taking the Austrian ELGA as an example.
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Methods of Documentation VII: EMR
Discharge Summary Forms
Here's a detailed look at the key components and guidelines for preparing a discharge summary:
Flow Sheet
Here's a closer look at the examples of flowsheets commonly used by nurses:
Graphic Sheet Documentation:
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Data Collection II
Data Reporting and Recording

