CPM Blog

SecTag -- Tagging Clinical Note Section Headers

Clinical notes are often divided into sections, or segments, such as "history of present illness" or "past medical history." These sections often have subsections as well, such as the "cardiovascular exam" section of the "physical exam." One can gain greater understanding of clinical notes by recognition of the section in which a concept lives. For instance, both a "past medical history" and the "family medical history" sections can contain a list of diseases, but the context decribes very different import to the patient about whom the note was written.

KnowledgeMap Learning Portfolio

KnowledgeMap Learning Portfolio collects trainee-created documents reflecting their direct patient experiences via the Electronic Medical Records (EMR), providing a rich log of a trainee's clinical exposure without requiring additional manual effort. The interface between the EMR system and Portfolio provides historical data from which trainees can continue to build their knowledge base, tagged to core learning objectives, and supplies the mentor the opportunity to review and evaluate trainee performance.

Homer Warner Award, AMIA 2008

A paper on a terminology of section headers received the 2008 Homer Warner Award: Denny JC, Miller RA, Johnson KB, Spickard A 3rd. Development and evaluation of a clinical note section header terminology. AMIA Annu Symp Proc. 2008 Nov 6:156-60.