Information organization in medical records: a Popperian approach
Abstract
Medical records are crucial resources for the entirety of standard healthcare practice. The amount, variety and complexity of data contained in records stored in medical institutions have required the use of information systems, with the aim to better meet the expectations of healthcare professionals and patients. In recent years, two approaches for information organization have been widely adopted to provide basis for medical information systems: ontologies and healthcare information models. In this paper, we develop a framework based on the theory of Three Worlds by Karl Popper in order to explain the processes that take place when medical records are created and manipulated in an encounter between a physician and a patient. Using this framework, we are able to distinguish different kinds of data available in medical records, which provides a better understanding of medical documentation. This increases the possibility of using such documentation as a data source for the previously mentioned approaches for information organization. The proposed framework allows the identification of four kinds of data and then it is tested in a description of a real clinical case. Finally, we present remarks and recommendations about the use of the identified kinds of data in the scope of medical information systems.
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