Aplicabilidad del mapa conceptual en la representación del conocimiento registrado en las historias clínicas del paciente

Abstract

The concept maps can be considered as signic objects and representations of knowledge. In Information Science and Librarianship are used in treatment, representation, organization and retrieval of information in traditional documents. However, in a specific documentation such as medical records, this methodology has not been applied. Thus, we present research whose problem is: How to apply the methodology of concept maps in knowledge representation and evolution of medical records? The aim: build a conceptual map of evolutions recorded in the medical records. This research has characteristics of an exploratory study. The analyzes were based on the functionalist method and content analysis. The corpus consists of 10 clinical histories of nephrology specialty. To build the maps we use the Cmap. The results show that the macrostructure of evolutions has attributes set to the categories: clinical evolution, evolution within the SOAP plan, among others. Regarding logic structure, attributes varied according to the types of diseases patients and the actions carried out by the doctor and the nurse.