background and objectives: standard clinical documentation is an integral part of quality patient care. this study aimed to explore compliance of two iranian teaching hospitals with the clinical documentation standards.   methods: a total of 400 records were surveyed. data were collected using a checklist of standard measures. the checklist comprised 15 items selected from relevant guidelines...

fast and holistic access to the patients’ clinical record is a major requirement of modern medical decision support systems (dss). while electronic health records (ehrs) have replaced the traditional paper-based records in most healthcare organization, the data entry into these systems remains largely manual. speech recognition technology promises substitution of the more convenient speech-base...

HealthInfoCDA denotes a health informatics educational intervention for learning about the clinical process through use of the Clinical Document Architecture (CDA). We hypothesize those common standards for an electronic health record can provide content for a case base for learning how to make decisions. The medical record provides a shared context to coordinate delivery of healthcare and is a...

Automating clinical and administrative processes via an electronic patient record (EPR) gives clinicians the point-of-care tools they need to deliver better patient care. However, to improve clinical practice as a whole and then evaluate it, healthcare must go beyond basic automation and convert EPR data into aggregated, multidimensional information. Unfortunately, few EPR systems have the esta...

Collecting and monitoring performance measure data are resource-intensive, requiring time and effort by a team that includes health care providers treating the patients and documenting their care, quality personnel monitoring and working to optimize performance rates, and quality abstractors, who extract information from the medical record. Recently, an additional group of people have become in...

Background and Objectives: Standard clinical documentation is an integral part of quality patient care. This study aimed to explore compliance of two Iranian teaching hospitals with the clinical documentation standards.   Methods: A total of 400 records were surveyed. Data were collected using a checklist of standard measures. The checklist comprised 15 items selected from relevant guidelines...