OpenSDE: Row modeling applied to generic structured data entry.

Abstract

Clinicians generally record medical narrative data, such as current complaints, physical examination, and progress notes, as free text in paper-based medical records. The medical narrative involves heterogeneous and detailed data that include the description of (multiple) occurrences of medical findings or symptoms that may progress over time. Structured, electronic recording of narrative data would facilitate the use of these data for research. The authors' OpenSDE application supports clinicians with the structured recording of narrative data in both research and care settings. Data entry is enabled using forms that are generated using domain-specific trees of medical concepts. For data storage, the authors have expanded the traditional row modeling methodology with additional columns that allow structured representation of medical narratives including descriptions of findings, multiple occurrences of findings, and the progression of findings over time.