[Registration of detailed data in the medical record or how to translate "impressions" into measurable observations].
Every medical case record represents a mass of data (texts, pictures, figures, etc.) in an unstructured form. The physician needs to retrieve this data via several access routes: temporal (dependent on date or sequences of events), type of data (diagnostic, treatment, clinical signs, laboratory findings, image descriptors, all with their interrelationships), or depending on the severity of the disease, etc. Retrieval of this data fulfils several functions: circulation of a case record among specialists, assistance in summarizing a long and complex clinical course, comparison of patients, research, and teaching. Three projects are described which have the same aim: structuring of the case record in order to retrieve detailed data on patients as individuals and describe clinical courses on the basis of measurable observations. This structure must be understandable to a computer (directly or indirectly) so that searches and comparisons can be performed automatically. The first project, entitled "indexed paragraph prototype" reproduces the structure of the problem-oriented case record and is designed to input the Medical Outpatients Department's follow-up notes into the computer. The second, "automatic language analysis", aims to exploit two characteristics of medical language, its omnipresence in the case record and its reliability, in view of its status as the spontaneous vehicle of communication between physicians. The third, "collection of clinical signs during consultation", is based on a prospective collection of all elements of clinical observation, structured temporally consultation by consultation. The purpose of precise collection of detailed and measurable observations in individual patients is to identify those among the clinical signs which display the greatest power of discrimination, i.e. those which best serve to predict the case's evolution.
Borst
F
F
Centre d'informatique hospitalière, Hôpital cantonal universitaire, Genève.
Scherrer
J R
JR
D000043:Abstracting and Indexing; D006751:Hospital Information Systems; D006801:Humans; D008487:Medical History Taking; D016347:Medical Records Systems, Computerized; D008501:Medical Records, Problem-Oriented; D009323:Natural Language Processing
L'enregistrement des données détaillées dans le dossier médical, ou comment traduire les "impressions" en observations mesurables.