title: Formal representation of a conceptual data model for the patient-based medical record.
abstract: We present a general architecture for the patient-based medical record as it is being developed for the SAMS, a private social security system. The conceptual data model is described in a convenient formal notation, the entity-relationship diagram. Although following the original formulation of the problem-oriented medical record (POMR), the data model was designed with a level of generalization that, functionally, makes structural differences between conventional and POMR no longer apparent. The main features of this model are its adaptability to individual work practices and its problem-oriented structure, including the representation of problems' evolution. This structure will enable physicians to organize the data, mostly collected elsewhere, by explicitly relating the facts that constitute a particular patient record, which is a simple way to store context information and clinical knowledge that is not part of patient data.
authors.affiliation: Dept. Biomatematica, Faculdade de Medicina de Lisboa, Portugal.
authors.forename: A
authors.initials: A
authors.lastname: Gouveia-Oliveira
authors.forename: L
authors.initials: L
authors.lastname: Lopes
mesh_terms: D003628:Database Management Systems; D006801:Humans; D008331:Management Information Systems; D016347:Medical Records Systems, Computerized; D008501:Medical Records, Problem-Oriented; D008962:Models, Theoretical