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
