Integration of clinical templates, to ensure that appropriate advice, drug titration, review of existing medications and investigations are undertaken may address some deficiencies.
GPs suggested various ways to measure quality in children including audits, clinical templates, questionnaires, ED visits, hospital admissions and antibiotic prescription rates.
To use ICNP terminology in clinical practice, the development of five different types of catalogue is suggested: subsets, nursing minimum dataset, care plans, clinical templates and order sets [ 6, 7].
However, it is likely that the recording of family history will improve over time particularly if (1) clinicians can be prompted to ask for this information by the use of structured clinical templates which can be offered to the clinician for use during the consultation or if (2) patients can record this information directly once they are able to access their medical record electronically.
11 26 This was thought to be due to different usage of clinical templates in the clinical system, with EMIS practices having ethnicity and family history included more often thereby prompting the user to enter this information in a more systematic fashion.
The early work of the Markle Communications for Health group has revealed a need for standards in the following areas: reference information models (RIM), data types, terminology, clinical documents, clinical templates, data interchange, implementation manuals, rules, tool sets, terminology services, security, identifiers, and guidelines.
Zhou L, Gurjar R, Regier R, Morgan S, Meyer T, Aroy T, Goldman DS, Hongsermeier T, Middleton B. A study on design and development of enterprise-wide concepts for clinical documentation templates.
The K-REC currently consists of a clinical scenario template, with two 'tested' scenarios.
One clinical scenario template was designed for the K-REC, with specific inclusion of each of the PICO components.
The K-REC contains a clinical scenario template that may be relevant to a variety of health professional disciplines and individual items relating to the scenario.
The final draft of the K-REC consisted of a clinical scenario template and nine items relating to that scenario (Additional file 1).
