Presentation of Structural Constraints for Discharge Note According to Clinical Document Architecture Standard.
- Author:
Hwa Jeong SEO
1
;
Seung Kwon HONG
;
Ji Yeon PARK
;
Jung Ae LEE
;
Yu Rang PARK
;
Ju Han KIM
Author Information
1. Seoul National University, Biomedical Informatics (SNUBI), Korea. juhan@snu.ac.kr
- Publication Type:Original Article
- Keywords:
Electronic Medical Record;
Health Level 7;
Clinical Document Architecture;
Discharge Note;
Standard;
Extensible Markup Language
- MeSH:
Electronic Health Records;
Health Level Seven;
Humans;
Retrospective Studies;
Seoul
- From:Journal of Korean Society of Medical Informatics
2005;11(2):189-198
- CountryRepublic of Korea
- Language:Korean
-
Abstract:
OBJECTIVE: HL7(Health Level 7) develops standards for the representation of clinical documents like discharge and consultation notes. The goal of the present study is to develop XML(eXtensible Markup Language)-based communication standard for discharge note. METHODS: This paper presents the use of XML for electronic communication in a document-based EMR, first, as a format for the exchange of structured message, and second, as a comprehensible way to represent patient document. A retrospective analysis of 1165 discharge notes, from the department Seoul National University Hospital, were extracted by querying OCS(Order Communication System) and taking every discharge note of main disease issued over one year period (2003.01.01~2003.12.31). RESULTS: An XML-based prototype for discharge note has been put into place representing the required "section" and "specific instance". In addition, a subset of the CDA(Clinical Document Architecture) Level One details has been described and integrated. CONCLUSION: Through the introduction of definitions for sections and specific instances, progress in the development of CDA Level Two and Three might be realized. An XML-based prototype was implemented, allowing a special view on XML data to generate this document type.
