임상문서구조 표준을 따르는 구조화된 퇴원요약지의 문서 제약사항의 표현
서화정1), 홍승권1), 이정애1), 박유랑1), 김주한*1)
1)서울대학교 의과대학 생명의료정보학연구실
Abstract : HL7(Health Level 7) develops standards for the representation of clinical documents such as discharge notes and consultation notes. The goal of the our research is standardization of communication between Hospital Information Systems using XML(eXtensible Markup Language)-based document representation standards. In this paper, we present a method by which discharge note can be used by an Internal Medicine Department. This information model implemented in a CDA(Clinical Document Architecture)-based prototype through the introduction of definitions like section and specific instance. It could satisfy the XML-based standard for the representation of clinical documents. The research reported in this paper has lead to the successful prototyping of a CDA-based structured discharge note. keyword : HL7, CDA, Discharge note, Standard, XML
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