Ontological and epistemological views of 'headings' in clinical records

Abstract

This paper presents a theoretical framework for analyzing the structure and use of headings in clinical narrative. We are researching the proposed UK national standard of headings for communicating clinical information. We investigate three topics with respect to these headings) conformance to standards and systems) coverage and reliability) navigation and interpretation. The method described here is used to analyse the three distinct topics in a coherent and systematic way deploying a variant of functional analysis to consider the meaningfulness and interpretation of headings from both the clinician' and system' perspectives.