Robinson D, Price C, Brown P J
NHS Centre for Coding and Classification, Loughborough, United Kingdom.
Proc AMIA Symp. 1998:840-4.
Documentation of the administrative aspects of clinical practice (fee claims, referrals, visits etc.) is essential and a controlled terminology for the electronic health care record needs to support this requirement. The Read Codes--used in the United Kingdom for over 10 years--include a chapter of administration terms for this purpose. The latest version, the Read Thesaurus, adopts a partially compositional approach to concept representation. We describe an extension of the ENV 1828 surgical procedure scheme developed as a provisional model to represent administrative procedures. Applicable concept fields, semantic links and modifiers are identified and compared. A compositional approach appears to provide a flexible and manageable method of representing administrative procedures, and readily accommodates regional variations.
临床实践管理方面的文档记录（费用报销、转诊、就诊等）至关重要，电子健康记录的受控术语需要支持这一要求。在英国已使用了十多年的Read编码为此包含了一章管理术语。最新版本的Read词库采用了部分组合式的概念表示方法。我们描述了作为表示管理程序的临时模型开发的ENV 1828外科手术方案的扩展。识别并比较了适用的概念字段、语义链接和修饰符。组合式方法似乎提供了一种灵活且易于管理的表示管理程序的方法，并且很容易适应地区差异。
