Writing an Entry Into a Clinical Record at or Near the Point of Care

At the point of care, search is done in order to find a Concept which describes a specific event that occurred during the course of patient care (e.g. documenting the findings related to a physical examination, diagnosis or surgical procedure into a form).

Creating Forms for Structured Data Entry

Data entry forms in clinical records are often designed for a specific documentation purpose. Designing the interface of a data entry forms and/or its content may entail associating Concepts with a template element or control. In highly structured forms, the design may involve specifying what Concepts should be available for selection. In less structured templates, the design may involve specifying the features useful for conducting an efficient and effective search. Thus, template designers may need to be able to search the whole terminology but also have the competencies to manually constrain the search by various filters and applying advanced functionalities, such as expression views and comparison between Concepts.

For more information on structured data entry, please refer to the "Structured data entry" sub-section.