Presentation of Structural Constraints for Discharge Note According to Clinical Document Architecture Standard

Seo, Hwa Jeong; Hong, Seung Kwon; Park, Ji Yeon; Lee, Jung Ae; Park, Yu Rang; Kim, Ju Han

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.