A MODEL FOR STRUCTURED DATA-ENTRY BASED ON EXPLICIT DESCRIPTIONAL KNOWLEDGE

Clinical narratives in patient records are usually recorded in free te xt, limiting the use of this information for research, quality assessm ent, and decision support. This study focuses on the capture of clinic al narratives in a structured format by supporting physicians with str uctured data entry (SDE). We analyzed and made explicit which requirem ents SDE should meet to be acceptable for the physician on the one han d, and generate unambiguous patient data on the other. Starting from t hese requirements, we found that in order to support SDE, the knowledg e on which it is based needs to be made explicit: we refer to this kno wledge as descriptional knowledge. We articulate the nature of this kn owledge, and propose a model in which it can be formally represented. The model allows the construction of specific knowledge bases, each re presenting the knowledge needed to support SDE within a circumscribed domain. Data entry is made possible through a general entry program, o f which the behavior is determined by a combination of user input and the content of the applicable domain knowledge base. We clarify how de scriptional knowledge is represented, modeled, and used for data entry to achieve SDE, which meets the proposed requirements.