Chueh H C, Raila W F, Berkowicz D A, Barnett G O
Laboratory of Computer Science, Massachusetts General Hospital, Boston, USA.
Proc AMIA Symp. 1998:730-4.
The clinical chart remains the fundamental record of outpatient clinical care. As this information migrates to electronic form, there is an opportunity to create standard formats for transmitting these charts. This paper describes work toward a Portable Chart Format (PCF) that can represent the relevant aspects of an outpatient chart. The main goal of the format is to provide a packaging medium for outpatient clinical charts in a transfer of care scenario. A secondary goal is to support the aggregation of comparable clinical data for outcomes analysis. The syntax used for PCF is Extended Markup Language (XML), a W3C standard. The structure of the PCF is based on a clinically relevant view of the data. The data definitions and nomenclature used are based primarily on existing clinical standards.
临床病历仍然是门诊临床护理的基本记录。随着这些信息向电子形式迁移,有机会创建用于传输这些病历的标准格式。本文描述了朝着可表示门诊病历相关方面的便携式病历格式(PCF)所做的工作。该格式的主要目标是在护理转移场景中为门诊临床病历提供一种打包介质。次要目标是支持对可比临床数据进行汇总以进行结果分析。PCF使用的语法是万维网联盟(W3C)标准的可扩展标记语言(XML)。PCF的结构基于对数据的临床相关视图。所使用的数据定义和术语主要基于现有的临床标准。