ArticleJournal of the American Medical Informatics Association : JAMIA
An electronic health record based on structured narrative.
Article in Journal of the American Medical Informatics Association : JAMIA. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 62 papers, 4 of them syntheses that pooled it.
What it found
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
62 citing papers in PubMed, 4 syntheses or guidelines pooled it.
- Integrating digital and narrative medicine in modern healthcare: a systematic review.Medical education online · 2025Pooled it
- Current approaches to identify sections within clinical narratives from electronic health records: a systematic review.BMC medical research methodology · 2019Pooled it
- Natural language processing systems for capturing and standardizing unstructured clinical information: A systematic review.Journal of biomedical informatics · 2017Pooled it
- Content overlap in nurse and physician handoff artifacts and the potential role of electronic health records: a systematic review.Journal of biomedical informatics · 2011Pooled it
- Identifying Medication Review Topics to Be Documented in a Structured Form in Electronic Health Record Systems: Delphi Consensus Survey.Journal of medical Internet research · 2025Article
- Data from Routine Primary Healthcare: Opportunities and Threats for Obesity Epidemiological Research.Portuguese journal of public health · 2025Article
- Deep learning models can predict violence and threats against healthcare providers using clinical notes.Npj mental health research · 2024Article
- Constructing a Clinical Patient Similarity Network of Gastric Cancer.Bioengineering (Basel, Switzerland) · 2024Article
- Evaluating compliance with the best practice guidelines for wrong-level surgery prevention in high-risk pediatric spine surgery.Spine deformity · 2024Article
- Distinguishing cardiac catheter ablation energy modalities by applying natural language processing to electronic health records.Journal of comparative effectiveness research · 2024Article
- The relationship between electronic health records user interface features and data quality of patient clinical information: an integrative review.Journal of the American Medical Informatics Association : JAMIA · 2023Review
- Impact of Electronic Health Records on Information Practices in Mental Health Contexts: Scoping Review.Journal of medical Internet research · 2022Article
- STO: Stroke Ontology for Accelerating Translational Stroke Research.Neurology and therapy · 2021Article
- Using computable knowledge mined from the literature to elucidate confounders for EHR-based pharmacovigilance.Journal of biomedical informatics · 2021Article
- Use of the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) for Processing Free Text in Health Care: Systematic Scoping Review.Journal of medical Internet research · 2021Article
- Clinical Documentation as End-User Programming.Proceedings of the SIGCHI conference on human factors in computing systems. CHI Conference · 2020Article
- Heart Failure Management Innovation Enabled by Electronic Health Records.JACC. Heart failure · 2020Review
- Can structured EHR data support clinical coding? A data mining approach.Health systems (Basingstoke, England) · 2020Article
- Electronic medical record implementation for a healthcare system caring for homeless people.JAMIA open · 2019Article
- Machine Learning in Relation to Emergency Medicine Clinical and Operational Scenarios: An Overview.The western journal of emergency medicine · 2019Review
2 more citing papers are in PubMed but not listed here.
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
10 authors.
Funding
Abstract
objectiveTo develop an electronic health record that facilitates rapid capture of detailed narrative observations from clinicians, with partial structuring of narrative information for integration and reuse.
designWe propose a design in which unstructured text and coded data are fused into a single model called structured narrative. Each major clinical event (e.g., encounter or procedure) is represented as a document that is marked up to identify gross structure (sections, fields, paragraphs, lists) as well as fine structure within sentences (concepts, modifiers, relationships). Marked up items are associated with standardized codes that enable linkage to other events, as well as efficient reuse of information, which can speed up data entry by clinicians. Natural language processing is used to identify fine structure, which can reduce the need for form-based entry. VALIDATION: The model is validated through an example of use by a clinician, with discussion of relevant aspects of the user interface, data structures and processing rules. DISCUSSION: The proposed model represents all patient information as documents with standardized gross structure (templates). Clinicians enter their data as free text, which is coded by natural language processing in real time making it immediately usable for other computation, such as alerts or critiques. In addition, the narrative data annotates and augments structured data with temporal relations, severity and degree modifiers, causal connections, clinical explanations and rationale.
conclusionStructured narrative has potential to facilitate capture of data directly from clinicians by allowing freedom of expression, giving immediate feedback, supporting reuse of clinical information and structuring data for subsequent processing, such as quality assurance and clinical research.
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Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.