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Stud Health Technol Inform ; 183: 195-200, 2013.
Article in English | MEDLINE | ID: mdl-23388281

ABSTRACT

The increasing use of synoptic operative reports in clinical settings represents a major milestone in the advancement of health information technology. Synoptic operative report templates enable clinicians to capture and display succinct clinical information in a standardized and logical manner. Synoptic operative report templates also provide the optimum goal of enriching personalized health information of a given patient at the point of care so as to support the exchange of clinical information across the continuum of multiple healthcare providers. However, most of the available synoptic operative report templates in many clinical settings do not incorporate interoperable standards in their design and implementation. This paper proposes a novice template (i.e., eSOR-SCI) that uses interoperable standards for its design and implementation.


Subject(s)
Documentation/standards , Electronic Health Records/standards , Forms and Records Control/standards , General Surgery/standards , Medical Record Linkage/standards , Practice Guidelines as Topic , Quality Assurance, Health Care/standards , Health Records, Personal , Internationality
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