GB/T 46283-2025Health informatics - Categorial structure for terminological systems of surgical procedures (English PDF)

Foreword

This document is in accordance with GB/T 1.1-2020 "Standardization Work Guidelines Part 1: Structure and Drafting Rules of Standardization Documents".

Drafting is scheduled.

This document is modified to adopt ISO 1828:2012 "Health informatics - Surgical terminology system - Classification structure".

This document has undergone the following structural changes compared to ISO 1828:2012.

---Sections 3.1.1 to 3.1.7 correspond to sections 3.1 to 3.7 of ISO 1828:2012, and sections 3.2.1 to 3.2.4 correspond to sections 3.8.1 to 3.8.4 of ISO 1828:2012.

Sections 3.8.4, 3.3.1 to 3.3.4 correspond to sections 3.9.1 to 3.9.4 of ISO 1828:2012;

---Sections 5.2 to 5.6 correspond to sections 5.1 to 5.5 of ISO 1828:2012;

--- Annexes A to C of ISO 1828:2012 have been deleted.

The technical differences between this document and ISO 1828:2012, and the reasons therefor, are as follows.

---The terminology and definitions for the "subject domain" in the "Healthcare Terminology System" have been changed (see 3.1.5, 3.1.6, and 3.5 of ISO 1828:2012).

3.6) Because the standard in the source is obsolete, modifications are made with reference to the currently valid standards;

---The normative references to ISO 17115 and EN 12264 (see section 4.1 of ISO 1828:2012) have been removed to adapt to my country's national conditions;

---The content of the objective has been modified (see 4.2, ISO 1828:2012 4.2) to adapt to my country's national conditions.

The following editorial changes have been made to this document.

---Notes in 3.8.4 have been deleted;

---The informative annex A of ISO 1828:2012, "Definitions derived from ISO 17115:2007, section 2.7 Terminology System," has been deleted.

Appendix B, "Classification Structure of the Latest and/or Widely Used Surgical Terminology System", and Informative Appendix C, "EN15521:2007"

The excerpt provides the definition and category of the entity. human anatomy.

Please note that some content in this document may involve patents. The issuing organization of this document assumes no responsibility for identifying patents.

This document was proposed and is under the jurisdiction of the China National Institute of Standardization.

Introduction

There are inconsistencies in my country's surgical terminology system, with different healthcare institutions using different methods to describe and classify surgical procedures.

These differences have, to some extent, affected the integration and sharing of relevant data, posing challenges to the development of health information systems and the conduct of scientific research.

This urgently needs to be unified. With the increasing international exchange and cooperation, this is particularly relevant in activities such as academic exchanges, transnational health services, and international multicenter clinical research.

In China, a unified surgical terminology system is also needed to ensure the accuracy of information transmission. ISO 1828:2012 serves as an internationally recognized standard for surgical terminology.

The internationally standardized classification structure of surgical terminology is widely used globally and helps reduce communication problems caused by terminology differences. (Health Information Technology) Technological advancements rely on a unified system and classification of surgical terminology; a lack of a unified terminology system increases the costs of information system development and maintenance.

This reduces the accuracy and efficiency of data processing.

In summary, the formulation of this document provides a unified standard for the classification structure of surgical terminology, which helps ensure the accuracy of health data and Consistency lays the foundation for the collection, storage, transmission, and analysis of health data, promotes data sharing among different health service institutions, and drives...

The development and utilization of health data.

Health informatics surgical terminology system classification structure

1 Scope

This document specifies the minimum features, minimum domain constraints, and UML (Unified Modeling Language) diagrams for the classification structure of surgical terminology.

Note 1.More specific features or more detailed sets of values can be used depending on the specific purpose.

Note 2.The classification structure supports interoperability by providing a general framework for developing interconnected terminology systems and for different terms.

The characteristics of the system are analyzed to deduce the relationships between the terminology system.

This document applies to the surgical terminology system for all surgical disciplines. This document includes only surgical procedures as defined in ISO 1087:2019.

The terminology section of a terminology system.

This document is applicable to.

---Organizations involved in the development or maintenance of multipurpose surgical terminology systems;

---An organization that develops and maintains software tools, which are used to analyze, generate, and map natural clinical language expressions.

Existing surgical terminology system;

---Develop and maintain software tools that can analyze, generate, and map natural clinical language expressions to existing surgical terminology systems.

The organization of tools.

This document is applicable to computer applications and the generation of electronic medical records, and has limited value for manual use.

This document is not intended for use by clinicians or hospital administrators.

2 Normative references

This document contains no normative references.

3 Terms and Definitions

The following terms and definitions apply to this document.