A Model for Structured Data Entry Based on Explicit Descriptional Knowledge

P. W. Moorman; A. M. van Ginneken; J. van der Lei; J. H. van Bemmel

doi:10.1055/s-0038-1635050

Methods of Information in Medicine, Table of Contents

Methods Inf Med 1994; 33(05): 454-463
DOI: 10.1055/s-0038-1635050

Original Article

Schattauer GmbH

A Model for Structured Data Entry Based on Explicit Descriptional Knowledge

Authors

P. W. Moorman

¹Department of Medical Informatics, Faculty of Medicine and Health Sciences, Erasmus University Rotterdam, The Netherlands

²Department of Internal Medicine, University Hospital Dijkzigt, Rotterdam, The Netherlands
A. M. van Ginneken

¹Department of Medical Informatics, Faculty of Medicine and Health Sciences, Erasmus University Rotterdam, The Netherlands
J. van der Lei

¹Department of Medical Informatics, Faculty of Medicine and Health Sciences, Erasmus University Rotterdam, The Netherlands
J. H. van Bemmel

¹Department of Medical Informatics, Faculty of Medicine and Health Sciences, Erasmus University Rotterdam, The Netherlands

Abstract

Abstract:

Clinical narratives in patient records are usually recorded in free text, limiting the use of this information for research, quality assessment, and decision support. This study focuses on the capture of clinical narratives in a structured format by supporting physicians with structured data entry (SDE). We analyzed and made explicit which requirements SDE should meet to be acceptable for the physician on the one hand, and generate unambiguous patient data on the other. Starting from these requirements, we found that in order to support SDE, the knowledge on which it is based needs to be made explicit: we refer to this knowledge as descriptional knowledge. We articulate the nature of this knowledge, and propose a model in which it can be formally represented. The model allows the construction of specific knowledge bases, each representing the knowledge needed to support SDE within a circumscribed domain. Data entry is made possible through a general entry program, of which the behavior is determined by a combination of user input and the content of the applicable domain knowledge base. We clarify how descriptional knowledge is represented, modeled, and used for data entry to achieve SDE, which meets the proposed requirements.

Keywords:

Computer Based Patient Records - Structured Data Entry - Knowledge Representation - Descriptional Knowledge - Modeling

Full Text

References

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