Building the User Interface for Structured Clinical Data Capture

Abstract

In the days prior to computerization, paper was the primary means of recording the details of an encounter of a patient with a care provider. Even after the advent of the EMR, paper is still with us: one important function of the EMR is to generate hard-copy intended for the patient or for third parties without EMR access. The traditional paper record for a given patient (placed in a folder) was arranged in a manner designed to facilitate access to information on multiple encounters. Thus, each patient’s information was sorted by date (most recent first), and within date by a means of organization represented by the acronym SOAP1 – Subjective findings (e.g., presenting complaint and symptoms related to it, past history), Objective findings (e.g., results of physical examination), Assessment details (e.g., lab test results) and Plan of action (i.e., orders).