OpenSDE: Row modeling applied to generic structured data entry

Clinicians generally record medical narrative data, such as current complaints, physical
examination, and progress notes, as free text in paper-based medical records. The medical narrative involves
heterogeneous and detailed data that include the description of (multiple) occurrences of medical findings or
symptoms that may progress over time. Structured, electronic recording of narrative data would facilitate the use
of these data for research. The authors’ OpenSDE application supports clinicians with the structured recording of
narrative data in both research and care settings. Data entry is enabled using forms that are generated using
domain-specific trees of medical concepts. For data storage, the authors have expanded the traditional row
modeling methodology with additional columns that allow structured representation of medical narratives
including descriptions of findings, multiple occurrences of findings, and the progression of findings over time