A framework for modelling the electronic medical record.

@article{Rector1993AFF,
  title={A framework for modelling the electronic medical record.},
  author={Alan L. Rector and W. A. Nowlan and Stephen Kay and Carole A. Goble and T. J. Howkins},
  journal={Methods of information in medicine},
  year={1993},
  volume={32 2},
  pages={
          109-19
        }
}
This paper presents a model for an electronic medical record which satisfies the requirements for a faithful and structured record of patient care set out in a previous paper in this series. The model underlies the PEN & PAD clinical workstation, and it provides for a permanent, completely attributable record of patient care and the process of medical decision making. The model separates the record into two levels: direct observations of the patient and meta-statements about the use of… CONTINUE READING

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