퇴원요약지를 이용한 CDA 문서 생성에 관한 가이드

김승희*1), 최진욱1)

1)서울대학교 의과대학 의공학교실

Abstract : Health Level 7(HL7) is developing standards for the representation of clinical documents. These document standards make up the HL7 Clinical Document Architecture (CDA). The CDA is a document markup standard that specifies the structure and semantics of clinical documents. A CDA document is a defined and complete information object that can include text, images, sounds, and other multimedia content. Being a part of the emerging HL7 version 3 family of standards, the CDA derives its semantic content from the shared HL7 Reference Information Model (RIM) and is implemented in Extensible Markup Language (XML). The aim of our work was to create a CDA document that allows exchanges of clinical and administrative information using HL7 CDA release 2, defined in HL7 V3 standard. We made XML based CDA document for discharge summary note in Seoul National University Hospital(SNUH). The research reported in this paper shows how CDA document could be made and facilitates other research to generate CDA document automatically.
keyword : Health Level 7, Clinical Document Architecture, Extensible Markup Language, discharge summary note

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