The documentation of care events is vital for patient care and is one of the factors that in uence the adoption of electronic medi- cal records by a health team. While the traditional registration technique is problem-oriented, it has one limitation: allowing only one relation be- tween problem and a clinical note; which in turn is re ected at the time of retrieving the information associated with each problem. This mod- elization fails to account that many problems have associated clinical notes and their description or evolutive progress may be related to a di erent problem. That is why we hypothesized a modi cation that al- lows physicians to write rst their clinical notes and then associate as many problems as necessary using labels. In turn, to improve interpre- tation of the problems we create a tag cloud where the most used are larger and vice versa, facilitating the record fetching task in cases where the associated information has labels. As a result of that, we observed that physicians received this modi cation with satisfaction, exibility in- creased when working with morbid patient loads, and the information inside their clinical notes became richer.
Sociedad Argentina de Informática e Investigación Operativa (SADIO)