Structured physical examination data: A modeling challenge

The success of systems facilitating collection of structured data by clinicians is largely dependent on the flexibility of the interface. The Open Record for CAre (ORCA) makes use of a generic model to support knowledge-based structured data entry for a variety of medical domains. An endeavor undertaken recently aimed to cover the broader area of Physical Examination by expanding the contents of the knowledge base. The model was found to be adequately expressive for supporting this task. Maintaining the balance between flexibility of the interface and constraints dictated by reliable retrieval, however, proved to be a considerable challenge. In this paper we illustrate through specific examples the effect of this trade off on the modeling process, together with the rationale for the chosen solutions and suggestions for future research focus.

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