Structures of clinical information in patient records

In order to support the preparation of the European Prestandard on "Communication of Electronic Health Care Record--Part 2: Domain Termlist" we carried out an analytical study about names of clinical documents, titles of generic sections, names of data elements, according to our terminological methods. We defined three layers of structures for clinical information: i) documents and sections, ii) clinical statements, iii) systematic details within statements. We prepared in correspondence many lists suitable to develop a principled coarse-grained markup for transmission and homogeneous browsing of disparate patient records across many institutions, without any preventive agreement on existing coding systems, data elements, record organization. This achievement is the basis for federated records, in particular for the virtual life-long patient record.