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First published December 7, 2003 as JAMIA PrePrint; doi:10.1197/jamia.M1375
Journal of the American Medical Informatics Association 2004;11(2):162-165
© 2004 American Medical Informatics Association

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Submitted on April 3, 2003
Accepted on November 6, 2003

OpenSDE: Row Modeling Applied to Generic Structured Data Entry

Renske K. Los MSc1*, Astrid M. van Ginneken MD, PhD1, Marcel de Wilde BSc1, and Johan van der Lei MD, PhD1

Affiliation of the authors: 1 Department of Medical Informatics, Erasmus MC - University Medical Center, Rotterdam, The Netherlands

* To whom correspondence should be addressed.

Clinicians generally record medical narrative data, such as current complaints, physical examination, and progress notes, as free text in paper-based medical records. The medical narrative involves heterogeneous and detailed data that includes the description of (multiple) occurrences of medical findings or symptoms that may progress over time. Structured, electronic recording of narrative data would facilitate the use of these data for research. Our OpenSDE application supports clinicians with the structured recording of narrative data in both a research and care setting. Data entry is enabled using forms that are generated using domain specific trees of medical concepts. For data storage we have expanded the traditional row modeling methodology with additional columns that allow structured representation of medical narratives including descriptions of findings, multiple occurrences of findings, and the progression of findings over time.




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