An ontology model for clinical documentation templates

Abstract

There are various kinds of clinical documents used in a hospital or clinic setting. With the emergence of Electronic Medical Records, efforts are being made to computerize these documents in a structured fashion in order to enable decision support. With structured data entry, because each fact about the patient is stored discretely and can be retrieved separately, information can be organized and presented in different ways, depending on the needs of the user. A typical structured clinical document contains a range of findings recorded by a physician, nurse or other care. These findings can be thought of as discrete pieces of information, called observations. These observations can be grouped together to form observation sets that can be placed under relevant headers within the document. When building information systems that support structured clinical documentation, these observations and sets are created and stored in catalogs. My thesis addresses the issue of building an ontology model for clinical documentation that supports the creation and management of an observations catalog, observation sets catalog and a clinical document catalog. The ontology can be used as an organizational tool for efficient maintenance of these catalogs. By tagging observations and observation sets with relevant attributes, it is possible to generate intelligent displays of data that are more flexible and dynamic.