Related Experiment Video
Updated: Nov 7, 2025

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts
Published on: September 20, 2018
A Preliminary Characterization of Canonicalized and Non-Canonicalized Section Headers Across Variable Clinical Note
Junjie Wang1, Shun Yu2, Anahita Davoudi3
1Chemical and Biomolecular Engineering.
None:
In the electronic health record, the majority of clinically relevant information is stored within clinical notes. Most clinical notes follow a set organizational structure composed of canonicalized section headers that facilitate clinical review and information gathering. Standardized section header terminologies such as the SecTag terminology permit the identification and standardization of headers to a canonicalized form. Although the SecTag terminology has been evaluated extensively for history & physical notes, the coverage of canonical section header terms has not been assessed across other note types. For this pilot study, we conducted a coverage study and characterization of canonical section headers across 5 common, clinical note types and a generalizability study of canonical section headers detected within two types of clinical notes from Penn Medicine.
Related Concept Videos
Formats for Nursing Documentation
Nursing Assessment Form:
• A nursing assessment form is a foundational document that captures detailed patient data from physical assessments and nursing histories.
• It includes patient demographics, medical history,...
Formulating and Validating Nursing Diagnosis I
There are thirteen domains...
Guidelines for Nursing Documentation II
Timely documentation is crucial to ensure continuity of care for patients. Any delays in recording or reporting medical information can result in medical errors and even adverse patient outcomes. From medication administration to diagnostic test results, every detail must be accurately and promptly documented to provide the best possible care for patients.
Guidelines for Nursing Documentation I
Factual:
The following points emphasize the significance of upholding accurate and unbiased documentation in healthcare.
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:
Methods of Documentation VI: Case Management Model
For example, a patient with a chronic...

