Document Detail

Modeling problem-oriented clinical notes.
MedLine Citation:
PMID:  23154581     Owner:  NLM     Status:  MEDLINE    
OBJECTIVES: To develop a model as a starting-point for developing a problem-oriented clinical notes application as a generic component of an Electronic Health Record (EHR).
METHODS: We used the generic conceptualization of Weed's problem-oriented medical record (POMR) to link progress notes to problems, and the Subjective, Objective, Assessment, Plan (SOAP) headings to classify elements of these notes. Health Level 7 (HL7) Version 3 and Unified Modeling Language (UML) were used for modeling. We looked especially at the role of Conditions and Concerns, and how to model these to document clinical reasoning.
RESULTS: We developed a generic HL7-based model for progress notes. In this model the specific clinical note has a condition as its reason. An assertion can be made about a condition. Any condition, observation or procedure can be a concern that has to be tracked. Utmost important is the relationship between constituting parts of a progress note and specially between progress notes by linking a progress note to conditions that are part of an earlier progress note. From this model a comprehensive hierarchical condition tree can be built. Several views, such as chronological, SOAP and condition-oriented, are possible. The clinical notes application is used in daily clinical practice. The model meets explicit design criteria and clinical needs.
CONCLUSIONS: With the comprehensive HL7 standard it is possible to model and map progress notes using SOAP headings and POMR methodology. We have developed a generic, flexible and applicable paradigm by using acts for each assessment that refer to a condition (1), by separating conditions from concerns (2), and by an extensive use of the working list act (3).
F H J M Cillessen; P F de Vries Robbé
Publication Detail:
Type:  Journal Article     Date:  2012-11-16
Journal Detail:
Title:  Methods of information in medicine     Volume:  51     ISSN:  0026-1270     ISO Abbreviation:  Methods Inf Med     Publication Date:  2012  
Date Detail:
Created Date:  2012-12-05     Completed Date:  2013-12-13     Revised Date:  2014-06-20    
Medline Journal Info:
Nlm Unique ID:  0210453     Medline TA:  Methods Inf Med     Country:  Germany    
Other Details:
Languages:  eng     Pagination:  507-15     Citation Subset:  IM    
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MeSH Terms
Electronic Health Records
Health Level Seven
Medical Records, Problem-Oriented*
Models, Theoretical*
Unified Medical Language System

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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