Critiquing based on automated medical records: An evaluation of HYPERCRITIC

Lei, Johan van der; Westerman, R. F.; Mosseveld, B.M.Th.

doi:10.1007/978-3-642-51659-7_70

Cited by 2 publications

(3 citation statements)

References 2 publications

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“…Furthermore, a simple record of unconnected observations often provides an inadequate basis for analysis. Meaningful medical audit, in particular, requires knowledge of the reasons for an action as well as details of the action itself [23]. The proposed twolevel model, which records decision making and justifications as meta observations, meets this requirement.…”

Section: Population Data For Research Clinical Audit and Health Servmentioning

confidence: 99%

Foundations for an Electronic Medical Record

Rector¹,

Nowlan²,

Kay³

1991

Methods Inf Med

157

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Given the many efforts currently under way to develop standards for electronic medical records, it is important to step back and reexamine the fundamental principles which should underlie a model of the electronic medical record. This paper presents an analysis based on the experience in developing the PEN & PAD prototype clinical workstation. The fundamental contention is that the requirements for a medical record must be grounded in its use for patient care. The basic requirement is that it be a faithful record of what clinicians have heard, seen, thought, and done. The other requirements for a medical record, e.g., that it be attributable and permanent, follow naturally from this view. We use the criteria developed to re-examine Weed’s Problem Oriented Medical Record and also relate the criteria to secondary uses of the medical record for population data, communications and decision support.

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Section: Population Data For Research Clinical Audit and Health Servmentioning

confidence: 99%

Foundations for an Electronic Medical Record

Rector¹,

Nowlan²,

Kay³

1991

Methods Inf Med

157

View full text Add to dashboard Cite

show abstract

“…Knowledge-based systems require relatively fine grained data and information about the justifications and relations between statement. (See [7] for a discussion of the limitations of existing medical records with regards to one knowledge-based system. )…”

Section: Integration With Knowledge-based Systemsmentioning

confidence: 99%

“…Equally, it is a response to the inability of most systems to record the role that observations have played in decision making or to give an adequate account of the constructs, such as "problems", used in the clinical decision-making process. Without such detailed information and a record of the clinical decision-making process, effective use of the medical record for decision making is severely restricted [7].…”

Section: Introductionmentioning

confidence: 99%

A Framework for Modelling the Electronic Medical Record

Rector

Nowlan²,

Kay³

et al. 1993

Methods Inf Med

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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 the previous paper in this series. The model is 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.

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Critiquing based on automated medical records: An evaluation of HYPERCRITIC

Cited by 2 publications

References 2 publications

Foundations for an Electronic Medical Record

Foundations for an Electronic Medical Record

A Framework for Modelling the Electronic Medical Record

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