title: Ontology-based reusable clinical document template production system.
abstract: Clinical documents embody professional clinical knowledge. This paper shows an effective clinical document template (CDT) production system that uses a clinical description entity (CDE) model, a CDE ontology, and a knowledge management system called STEP that manages ontology-based clinical description entities. The ontology represents CDEs and their inter-relations, and the STEP system stores and manages CDE ontology-based information regarding CDTs. The system also provides Web Services interfaces for search and reasoning over clinical entities. The system was populated with entities and relations extracted from 35 CDTs that were used in admission, discharge, and progress reports, as well as those used in nursing and operation functions. A clinical document template editor is shown that uses STEP.
authors.affiliation: Seoul National University, Seoul, Korea.
authors.forename: Sejin
authors.initials: S
authors.lastname: Nam
authors.forename: Sungin
authors.initials: S
authors.lastname: Lee
authors.forename: James G Boram
authors.initials: JG
authors.lastname: Kim
authors.forename: Hong-Gee
authors.initials: HG
authors.lastname: Kim
mesh_terms: D057286:Electronic Health Records; D005568:Forms and Records Control / Q000379:methods*; D055991:Health Records, Personal; D016247:Information Storage and Retrieval / Q000379:methods*; D008498:Medical Record Linkage / Q000379:methods*; D009323:Natural Language Processing; D056910:Republic of Korea