INTRODUCTION: Electronic health records (EHR) that contemplate specific information for physiotherapy and cater to the required standard and data communication are more necessary each day. Archetype based modeling may allow the construction of EHR that attempts the patient's assistance needs, ensuring the interoperability between systems and its usability. In these circumstances, the archetype creation is a crucial and determinant step for a specific and adequate EHR for physical therapy evaluation of patients with spinal cord injury (SCI). The aim of this study was to create archetypes and represent through the definition of a clinical data set for evaluation of patients with SCI, describing the challenges, the difficulties and the perspectives during the system's development and the modeling. METHODS: Exploratory study, divided in two phases: definition and validation of clinical data set for physical therapy functional evaluation of patients with SCI and archetype development based on the data defined, using the OpenEHR Archetype Editor. RESULTS: 24 archetypes were created after the development of a data set for physical therapy functional evaluation of patients with SCI. After that, a prototype was developed after the archetype "Mobility" of the "Motor Evaluation" part to visualize the EHR interface. CONCLUSION: The data set developed was essential for the archetype's creation. This approach facilitates a functional evaluation with relevant data, and allows a complete and adequate evaluation with easy access to the data.
Health evaluation; Data collection; Electronic health records; Information systems; Spinal cord injuries
