Syntagmatic Modelling: Proposal for Indexical Representation of Evolutions of Notes in Patient's Records

摘要

The aim of this paper is to propose a model indexical representation, using the syntagms referring to the names of diseases, symptoms and signs recorded in the evolution of notes in patient's record, aiming the organization and access to information of these documents with greater precision. Qualitative research based on Content Analysis (CA), was carried on having as its locus the Walter Cantidio University Hospital, Federal University of Ceara, Fortaleza, Brazil. The corpora consist of twenty evolutions of two Patient's Records, totaling eight volumes. Evolution was read and the syntagms referring to diseases, symptoms and signs were selected, and the index was organized with the mapped syntagms. Findings: 1200 syntagms referring to the names of diseases, symptoms and signs are presented according to the indexes, considering that the syntagms accurately state the particularity of the information recorded in the evolution of notes in patient's record and may contribute to the access and retrieval of information with better precision in the Medical and Statistics Archives Services (MSAS). This paper shows that the use of syntagms make possible to offer access and retrieval of information with higher added value in the context of the evolution of notes in patient's record, since they express the substance of what they name. We consider that a structured information retrieval system is highly relevant for Medical and Statistics Archives Services (MSAS). The syntagms bring contributions in understanding the planning of patient care actions and are a tool for researchers in context evaluation of the diseases treated in the health organizations. We infer that just as in any other domain of knowledge, in the context of this research, such modeling should also observe the stages of definition of the lexicon and base symbols, definition of a grammar to be adopted and definition of semantics that will at the end contribute to the construction of indexes, in this case, constituted by the syntagms. This fact is effective as a paradigm shift in the use of uniterms or concepts composed of a maximum of three lexical units for the indexical representation of health documentation, such as Patient's Records. Finally, the data from this research can be reused for other qualitative studies allowing other perceptions regarding the use of syntagms for indexical representation of MSAS and contribute to more specific evidence-based medicine studies and also to other research themes: patient speech, therapy and exams.