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BMC Medical Informatics and Decision Making
Published in: BMC Medical Informatics and Decision Making 1/2006

Open Access 01-12-2006 | Research article

Structured data entry for narrative data in a broad specialty: patient history and physical examination in pediatrics

Authors: Sacha E Bleeker, Gerarda Derksen-Lubsen, Astrid M van Ginneken, Johan van der Lei, Henriëtte A Moll

Published in: BMC Medical Informatics and Decision Making | Issue 1/2006

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Abstract

Background

Whereas an electronic medical record (EMR) system can partly address the limitations, of paper-based documentation, such as fragmentation of patient data, physical paper records missing and poor legibility, structured data entry (SDE, i.e. data entry based on selection of predefined medical concepts) is essential for uniformity of data, easier reporting, decision support, quality assessment, and patient-oriented clinical research. The aim of this project was to explore whether a previously developed generic (i.e. content independent) SDE application to support the structured documentation of narrative data (called OpenSDE) can be used to model data obtained at history taking and physical examination of a broad specialty.

Methods

OpenSDE was customized for the broad domain of general pediatrics: medical concepts and its descriptors from history taking and physical examination were modeled into a tree structure.

Results

An EMR system allowing structured recording (OpenSDE) of pediatric narrative data was developed. Patient history is described by 20 main concepts and physical examination by 11. In total, the thesaurus consists of about 1800 items, used in 8648 nodes in the tree with a maximum depth of 9 levels. Patient history contained 6312 nodes, and physical examination 2336. User-defined entry forms can be composed according to individual needs, without affecting the underlying data representation. The content of the tree can be adjusted easily and sharing records among different disciplines is possible. Data that are relevant in more than one context can be accessed from multiple branches of the tree without duplication or ambiguity of data entry via "shortcuts".

Conclusion

An expandable EMR system with structured data entry (OpenSDE) for pediatrics was developed, allowing structured documentation of patient history and physical examination. For further evaluation in other environments, the tree structure for general pediatrics is available at the Erasmus MC Web site (in Dutch, translation into English in progress) [1]. The generic OpenSDE application is available at the OpenSDE Web site [2].
Appendix
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Metadata
Title
Structured data entry for narrative data in a broad specialty: patient history and physical examination in pediatrics
Authors
Sacha E Bleeker
Gerarda Derksen-Lubsen
Astrid M van Ginneken
Johan van der Lei
Henriëtte A Moll
Publication date
01-12-2006
Publisher
BioMed Central
Published in
BMC Medical Informatics and Decision Making / Issue 1/2006
Electronic ISSN: 1472-6947
DOI
https://doi.org/10.1186/1472-6947-6-29

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