title: Structuring clinical information in healthcare records.
abstract: 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.
authors.affiliation: CNR-ITBM, Roma, Italy. angelo@itbm.rm.cnr.it
authors.forename: A
authors.initials: A
authors.lastname: Rossi Mori
authors.forename: F
authors.initials: F
authors.lastname: Consorti
mesh_terms: D003625:Data Collection; D005060:Europe; D006801:Humans; D007558:Italy; D008492:Medical Informatics Computing; D016347:Medical Records Systems, Computerized; D012984:Software; D018875:Vocabulary, Controlled