Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Health Care Processes and Decision Making
Lecture:The clinical process - overview of the classic paradigm
Gathering data and analyzing findings
Making a diagnosis
The impact of EHRs and technology on clinical decision-making
Slide content:Organization: How Clinicians Organize Information Narrative structure Rearranged into a history and physical format Further rearranged into a hierarchy Reformulated into a computable structure for utilization by clinical information systems 8
Slide notes:In addition to using many different types of information, clinicians organize and reorganize information in several ways as they manage a patient. Information typically begins in a narrative structure, becomes rearranged into a highly structured history and physical format, and then is rearranged again into meaningful groupings in a hierarchy, as described by Evans and Gadd [ gad ] . The manner of recording information, such as the SOAP [ soap ] (subjective, objective, assessment, and plan) note, can be helpful in supporting the clinicians thinking, and other ad hoc structures are used as needed. With the use of clinical information systems, much of the diagnostic information, such as lab results, radiology results, and data from medical devices, is provided to the clinician in electronic format. Each clinician typically enters his or her patient assessment, notes, and treatment plan directly into the EHR or clinical information system. This system provides a central location where all clinicians engaged in the patients care can access patient information and document their own clinical actions in a single electronic patient record, presenting a complete picture of the patients care and progress. Also, patient information may be aggregated or reformulated in an electronic manner that supports reporting capabilities, such as clinical decision support, quality improvement activities, and research, based on patient populations. 8