GB/T 25514-2010Health informatics -- Controlled health terminology -- Structure and high-level indicators (English PDF)

Foreword

This standard uses the translation method equivalent to ISO/T S17117..2002 "health information science healthy controlled vocabulary structure and high-level indicators" (English version).

Appendix A to this standard is an informative appendix and Appendix B is a normative appendix.

This standard is proposed and centralized by China Standardization Research Institute.

The drafting unit of this standard. General Hospital of Chinese People's Liberation Army, China Institute of Standardization.

Introduction

In 1839, WiliamFarr stated in his first annual report on the basic situation of birth, death and marriage in the United Kingdom. "The inquiry system the term in the system is as important as the weight in the physical sciences and should be developed immediately. "Since then, the majority of the scientists have been strong Tune this theme. At present, people have been widely recognized the need for healthy records of controlled vocabulary (E-1238, E-1239, E-1384, E-1633, ENV 12017). The controlled vocabulary provides a convenient system statistics. These statistics can be organized from various levels of granularity and therefore can be extended to question-based clinical record retrieval, classification of financial systems, or number of results for a given population according to. As the term continues to grow, maintaining a wide range of terms becomes a heavy job. Not a good structure, large capacity of the terms can not provide the corresponding interoperability, which is today's increasingly complex electronic health records required by the program.

The solution to the problem is due to the standard. In the past 10 years, medical informatics researchers have been studying controlled vocabularies. They were examined the structure and content of the terminology that existed at that time, the reason why they were not suitable for the specific demand, and proposed the corresponding solution. in in some places, the solution is already in use and has gained new experience. It is time to summarize these experiences and publish a sustainable one Development of controlled medical vocabulary standards set the time.

At the international level, ISO/TC215/WG3 summarizes these experiences and, for the first time, has developed it as a technical specification ISO/T S17117 Standardized work requirements in the field of health information science.

This standard uses the ISO/T S17117 all the technical content, so that the field of standardization of health information in the concept of expression level can Enough to keep in line with international practice, so as to support China's health information standards of international standards. The development of this standard on China's health information science Domain terminology of the norms, integration and use of important guiding significance.

Health informatics healthy controlled vocabulary Structure and high-level indicators

1 Scope

This standard describes the health and control of the vocabulary required and sufficient important ideas.

This standard applies to all areas where health protection information needs to be kept and used.

2 Normative reference documents

The terms of the following documents are hereby incorporated by reference into this standard. Whichever is the date of the reference file, which is followed by all (Not including the contents of the errata) or the revised version shall not apply to this standard, however, the parties who encourage the agreement under this standard are no use of the latest version of these files. For undated references, the latest edition applies to this standard.

Information technology - Metadata registration system (MDR) - Part 3. Registration system - Meta - model and basic - GB/T 18391.3-2009 Attribute (ISO/IEC 11179-3.:2003, IDT) Working Principles and Methods of ISO 704 Terminology ISO 860 terminology work and terminology consistent ISO 1087-1 Terminology - Work vocabulary - Part 1. Theory and application ISO 1087-2 terminology work vocabulary computer applications ISO 12620 Computer application data classification for terminology Information technology - Vocabulary - Part 4. Organization of data ISO/IEC 2382-4 ISO/IEC/T R9789 Information technology - Data elements for data exchange Organization and presentation guidelines Coding methods and principles E-1284 Guidelines for the development of clinical terminology for e-health archives E-1712 Clinical laboratory test and analyte designation standard specification Classification Structure of Semantic Expression Model of Health Informatics Concept System

3 Terms and definitions

The following terms and definitions apply to this standard.

Terminology

In a particular field, the term set representing the concept of the system.

Note. This means that from the published goals and scope, one can determine the extent to which this expression covers a particular area.

Healthy controlled vocabulary controledhealthterminology the term set for clinical application.

Note. This means that in the specific expression field, within the target and scope of the term, consistent with the granularity of the practice, for the content and structure.

Classification

The set of data for a particular domain is abstract at the specified level.

Note 1. The fixability of abstract levels that can be expressed by the classification system is often extended, and when the classification is applied to different user groups, Before the account classification model.

Note 2. See Appendix A for the history of classification.