Structuring clinical information in healthcare records
Rossi Mori, A.; Consorti, F.
Studies in Health Technology and Informatics 68: 862-865
1999
ISSN/ISBN: 0926-9630 PMID: 10725020 Document Number: 504178
We carried out an analytical study about names of clinical documents, titles of generic sections, names of data elements, to prepare the European Prestandard CEN ENV13606-2 on "Health Informatics--Communication of Electronic Health Care Record--Part 2: Domain Termlist". The goal of the standard is to facilitate transmission and/or homogeneous browsing of clinical information from disparate patient records, without any preliminary agreement on coding systems, data elements, record organization. With the assistance of the members of CEN/TC251/PT27 and under the control of CEN/TC251/WG I and WG II, we defined three layers to structure clinical information (structuring records into complexes, complexes into statements, statements into details) and we prepared many lists suitable to represent coarse-grained information about the different constructs used in the above layers.