Topics - Clinical Documentation
Clinical documentation is not merely narrative text recorded in software. It is a clinical asset that supports safe decision-making, interdisciplinary coordination, longitudinal accountability, and continuity of care across a patient’s care pathway. In parallel, expectations are rising for structured, semantically anchored, interoperable data - and for its responsible reuse in secondary contexts, including quality measurement and research.
On this page, you will find selected topics from medical informatics and clinical information design, grounded in over 30 years of experience in solution design for clinical information systems. The content is practice-oriented and standards-based (including HL7 FHIR, openEHR, and clinical terminologies), with a focus on robust information models for primary systems and clinical platforms.
-
Electronic Health Record
A concise, standards-oriented introduction to EMR design: key concepts, a logical baseline architecture, and the building blocks needed for longitudinal, interoperable clinical documentation.
-
Diagnosis & Problem List
The diagnosis and problem list is the clinical index of the medical record. It brings structure to longitudinal care by tracking problems and diagnoses over time, including their lifecycle, status, and coding.
-
Episode-Oriented Record
The episode-oriented medical record is a high-level organising layer for clinical documentation. It groups medical record entries across encounters into Episodes of Care and enables consistent derived views and lists.