Definitions Management: A Semantics-Based Approach for Clinical Documentation in Healthcare Delivery

Structured Clinical Documentation is a fundamental component of the healthcare enterprise, linking both clinical (e.g., electronic health record, clinical decision support) and administrative functions (e.g., evaluation and management coding, billing). Documentation templates have proven to be an effective mechanism for implementing structured clinical documentation. The ability to create and manage definitions, i.e., definitions management, for various concepts such as diseases, drugs, contraindications, complications, etc. is crucial for creating and maintaining documentation templates in a consistent and cohesive manner across the organization. Definitions management involves the creation and management of concepts that may be a part of controlled vocabularies, domain models and ontologies. In this paper, we present a realworld implementation of a semantics-based approach to automate structured clinical documentation based on a description logics (DL) system for ontology management....

• Type: Conference
• Year: 2005
• Where: SEMWEB
• Authors: Vipul Kashyap, Alfredo Morales, Tonya Hongsermeier, Qi Li
• Keywords: Definitions Management, Documentation Templates, SEMWEB 2005, Structured Clinical Documentation