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Related Experiment Videos

A computer-based tool for generation of progress notes

K E Campbell1, K Wieckert, L M Fagan

  • 1Section on Medical Informatics, Stanford University, CA 94305-5479.

Proceedings. Symposium on Computer Applications in Medical Care
|January 1, 1993
PubMed
Summary
This summary is machine-generated.

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IVORY, a tool using clinical findings, creates progress notes faster than word processors. Its structured vocabulary aids note generation and SNOMED III coding, with physician input guiding improvements for clinical use.

Area of Science:

  • Medical Informatics
  • Clinical Documentation

Background:

  • Efficient clinical documentation is crucial for healthcare.
  • Current methods like word processors can be time-consuming.
  • Structured data supports improved coding and analysis.

Purpose of the Study:

  • To evaluate the efficiency of IVORY, a computer-based tool for progress note generation.
  • To assess the utility of a structured vocabulary for clinical findings in documentation.
  • To identify necessary improvements for IVORY's routine clinical adoption.

Main Methods:

  • Developed IVORY, a tool using clinical findings as the basic unit for progress notes.
  • Created a structured vocabulary for clinical findings.
  • Conducted observational studies with physician participation in vocabulary development.

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Main Results:

  • IVORY generates progress notes more efficiently than character-based word processors.
  • The structured vocabulary supports the generation of both prose notes and SNOMED III codes.
  • Physician feedback identified areas for improvement for clinical acceptance.

Conclusions:

  • IVORY offers a more efficient approach to clinical progress note documentation.
  • A structured vocabulary is key to enabling efficient note generation and coding.
  • Ongoing physician collaboration is essential for refining tools like IVORY for practical use.