Document Detail

Modeling Problem-oriented Clinical Notes.
MedLine Citation:
PMID:  23154581     Owner:  NLM     Status:  Publisher    
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 Nov 
Date Detail:
Created Date:  2012-11-16     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0210453     Medline TA:  Methods Inf Med     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Felix Cillessen, Radboud University Nijmegen Medical Centre, 33 P.O. Box 9101, 6500 HB Nijmegen, The Netherlands, E-mail:
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