CDA의 문서 제약사항을 이용한 유방암센터 수술기록지의 구조적 표현 방법

서화정1), 윤성태*1), 황기태2), 김주한3)

1)Graduate School of Public Health Gachon Medical School
2)Dept. of General Surgery
3)Seoul National University Biomedical Informatics (SNUBI)

Abstract : As the needs for medical information has been increasing, the construction of an EMR (Electronic Medical Record) or CIS (Clinical Information System) spreads out rapidly across the country. These systems aim for performance of the studies on clinical trial including information on multifaceted treatment progress, prediction and customized medical treatments by analyzing relationships between biological and hereditary information in the long run. We present a methodology supporting systematically a variety of forms of document and its acquirement changeable from time to time which are required for clinical studies and the construction of information system on clinical demonstration based on formalization and international standards. By doing that, the new way of tracing down the relevance of a cancer and bad disease by using hereditary information is suggested, which is not detectable through a patient’s clinical test or measurements.
keyword : HL7, CDA, operation note, standard, XML

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