The problem-oriented medical synopsis: coding, indexing, and classification sub-model

Abstract

A clinical information system consists of four major components: the clinical database, decision support, data analysis (including outcomes), and the development system. We have created such a system using generally available database methodology. The system is documented using a conceptual model, a physical model, and sub-models for individual components. A key sub-model of the clinical database, for record-keeping, has been defined for coding, indexing, and classification of the medical narrative typically encountered in medical records. We describe an approach to the development of the coding component that results in a hybrid system for recording information, locating indexed information, and summarizing it for analysis of outcomes. These are based on a primary term list--the problem glossary; SNOMed--the Systematized Nomenclature of Medicine (3rd. edition); and ICD-9-CM. The relationship with the UMLS is also discussed.