Summary
Objectives: To develop a model as a starting-point for developing a problem-oriented clinical
notes application as a generic component of an Electronic Health Record (EHR).
Methods: We used the generic conceptualization of Weed’s problem-oriented medical record (POMR)
to link progress notes to problems, and the Subjective, Objective, Assessment, Plan
(SOAP) headings to classify elements of these notes. Health Level 7 (HL7) Version
3 and Unified Modeling Language (UML) were used for modeling. We looked especially
at the role of Conditions and Concerns, and how to model these to document clinical
reasoning.
Results: We developed a generic HL7-based model for progress notes. In this model the specific
clinical note has a condition as its reason. An assertion can be made about a condition.
Any condition, observation or procedure can be a concern that has to be tracked. Utmost
important is the relationship between constituting parts of a progress note and specially
between progress notes by linking a progress note to conditions that are part of an
earlier progress note. From this model a comprehensive hierarchical condition tree
can be built. Several views, such as chronological, SOAP and condition-oriented, are
possible. The clinical notes application is used in daily clinical practice. The model
meets explicit design criteria and clinical needs.
Conclusions: With the comprehensive HL7 standard it is possible to model and map progress notes
using SOAP headings and POMR methodology. We have developed a generic, flexible and
applicable paradigm by using acts for each assessment that refer to a condition (1),
by separating conditions from concerns (2), and by an extensive use of the working
list act (3).
Keywords
Electronic health records - problem-oriented medical records - health level 7
