Medical decision support in clinical record management systems

The clinical record is a primary support for the diagnostic process performed by physicians. The development of a clinical record management system can significantly improve the quality of patient care by properly supporting the physicians´ tasks and, in particular, the diagnostic process. We address some key issues in designing a medical decision support system. Acquisition of medical knowledge is supported by a knowledge editor based on a conceptual model of diseases, aetiologies, evidence and their relationships. Diagnostic support is carried out by an algorithm which, according to the production rules generated by the knowledge editor and to the patient´s clinical data, formulates a set of diagnostic hypotheses and suggests tests and examinations for their validation. The definition of an internal model for the clinical record allows for clinical data from different departments to be integrated. On the other hand, the definition of external models allows for custom presentations of clinical data to be created