Structured Data Entry for Pediatric Patient History and Physical Examination
Author Information
Author(s): Sacha E. Bleeker, Gerarda Derksen-Lubsen, Astrid M. van Ginneken, Johan van der Lei, Henriëtte A. Moll
Primary Institution: Erasmus MC – Sophia, Rotterdam, The Netherlands
Hypothesis
Can a structured data entry application be effectively used for documenting pediatric patient history and physical examination?
Conclusion
An expandable EMR system with structured data entry for pediatrics was developed, allowing structured documentation of patient history and physical examination.
Supporting Evidence
- The EMR system developed allows for structured recording of pediatric narrative data.
- The thesaurus consists of about 1800 items used in 8648 nodes.
- User-defined entry forms can be created without affecting the underlying data representation.
Takeaway
This study created a computer program that helps doctors record patient information in a clear and organized way, making it easier to understand and share.
Methodology
The OpenSDE application was customized for pediatrics, modeling medical concepts into a tree structure for structured data entry.
Limitations
The study's initial assessment was limited to five volunteer pediatricians, which may not represent broader usability.
Participant Demographics
Five volunteer (trainee) pediatricians participated in the assessment.
Digital Object Identifier (DOI)
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