| Modeling Problem-oriented Clinical Notes. | |
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MedLine Citation:
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PMID: 23154581 Owner: NLM Status: Publisher |
Abstract/OtherAbstract:
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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). |
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Authors:
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F H J M Cillessen; P F de Vries Robbé |
Publication Detail:
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Type: JOURNAL ARTICLE Date: 2012-11-16 |
Journal Detail:
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Title: Methods of information in medicine Volume: 51 ISSN: 0026-1270 ISO Abbreviation: Methods Inf Med Publication Date: 2012 Nov |
Date Detail:
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Created Date: 2012-11-16 Completed Date: - Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 0210453 Medline TA: Methods Inf Med Country: - |
Other Details:
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Languages: ENG Pagination: - Citation Subset: - |
Affiliation:
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Felix Cillessen, Radboud University Nijmegen Medical Centre, 33 P.O. Box 9101, 6500 HB Nijmegen, The Netherlands, E-mail: F.Cillessen@mi.umcn.nl. |
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From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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