A Framework for Modelling the Electronic Medical Record

A. L. Rector; W. A. Nowlan; S. Kay; C. A. Goble; T. J. Howkins

doi:10.1055/s-0038-1634902

Methods of Information in Medicine, Inhaltsverzeichnis

Methods Inf Med 1993; 32(02): 109-119
DOI: 10.1055/s-0038-1634902

Original Article

Schattauer GmbH

A Framework for Modelling the Electronic Medical Record

A. L. Rector

¹Medical Informatics Group, Department of Computer Science, University of Manchester, Manchester, UK

,

W. A. Nowlan

¹Medical Informatics Group, Department of Computer Science, University of Manchester, Manchester, UK

,

S. Kay

¹Medical Informatics Group, Department of Computer Science, University of Manchester, Manchester, UK

,

C. A. Goble

¹Medical Informatics Group, Department of Computer Science, University of Manchester, Manchester, UK

,

T. J. Howkins

¹Medical Informatics Group, Department of Computer Science, University of Manchester, Manchester, UK

› Institutsangaben

Abstract

Abstract:

This paper presents a model for an electronic medical record which satisfies the requirements for a faithful and structured record of patient care set out in a previous paper in this series. The model underlies the PEN & PAD clinical workstation, and it provides for a permanent, completely attributable record of patient care and the process of medical decision making. The model separates the record into two levels: direct observations of the patient and meta-statements about the use of observations in decision making and the clinical dialogue. The model is presented in terms of “descriptions” formulated in the Structured Meta Knowledge (SMK) formalism, but many of its features are more general than the specific implementation. The use of electronic medical records based on the model for decision support and the analysis of aggregated data are discussed along with potential use of the model in distributed information systems.

Key-words

Medical Record - Information Models - Standards - Problem-Oriented Medical Record - Coding Systems

Volltext

Referenzen

REFERENCES
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