3-使用LOINC、SNOMED-CT与OID介绍-ok

CHIMA卫生信息共享标准培训课程HL7Taiwan协会秘书长范士展[e-mail]7TaiwanGoogle论坛:使用LOINC、SNOMED与OID介绍(1小时)1.使用LOINC2.SNOMED应用于HL73.OID介绍使用LOINC下载安装LOINC使用ACCESS使用RELMA下载安装LOINC请至官方网站下载最新版LOINC。网站：。若想深入研究LOINC者，可下载UsersGuide。下载需要账号密码，若您没有，需先注册。一切都是免费。下载内容包含有LOINC与RELMA。前者是LOINC单纯就是MSACCESS数据库；后者是提供用户接口，作为内部编码与LOINC间的对应。目前最新版本为：LOINC：2009年01月10日2.26RELMA：2009年01月10日3.25使用MSAccess自定义查询–DocumentType查询结果–DocumentType自定义查询–SectionType查询结果–SectionType使用RELMA查询关键词查询结果编码详细内容进阶文件应用于HL7简介文件名称：UsingSNOMEDCTinHL7Version3;ImplementationGuide,Release1.4(在Foundation目录下)目的ThepurposeofthisguideistoensurethatHL7Version3standardsachievetheirstatedgoalofsemanticinteroperabilitywhenusedtocommunicateclinicalinformationthatisrepresentedusingconceptsfromSNOMEDClinicalTerms®(SNOMEDCT)重要网址简介ClinicalfindingProcedureObservableentityBodystructureOrganismSubstancePharmaceutical/biologicproductSpecimenSpecialconceptPhysicalobjectPhysicalforceEventEnvironmentorgeographicallocationSocialcontextSituationwithexplicitcontextStatingandscalesLinkageconceptQualifiervalueRecordartifact目前所涵盖编码结构（Hierarchies)有SNOMEDCT简介主要是透过Concept、Description与Relationship三个重要元素建构Term之描述。concept：(概念)具有临床上意义者，有唯一辨识码（ConceptID)。文字表现上是以人可阅读之描述，此名称特殊定义为FullySpecifiedName(FSN)每个concept会与其他的concept有关连。ConceptGranularity:(概念尺度)：如右图SNOMEDCT简介Descriptions：（描述）描述是用一个term(词组）或name(名词）来说明概念。每个描述都有自己的DescriptionID(描述代码）。一个概念代码可能会有多个描述代码。例如：概念代码2229806的描述代码有：FullySpecifiedName:Myocardialinfarction(disorder):DescriptionID751689013Preferredterm:Myocardialinfarction:DescriptionID37436014Synonym:Cardiacinfarction:DescriptionID37442013Synonym:Heartattack:DescriptionID37443015SNOMEDCT简介Relationship:(关连）概念与概念间有四种关类型：Defining(定义)Qualifying(限制)Historical(历史)Additional(附加)每一个概念是透过与其关连的概念，做逻辑上定义。除了根概念（SNOMEDCTConcept)外，每一个使用中（Active)概念，至少会有一个IS_A与父概念关连。IS_A关连就是一种定义特性（definingcharacteristics)关连又是透过一些属性定义描述之。（约50多种属性）CliniClue软件工具简介SNOMEDCT查询辅助软件网址：概念代码描述代码关联属性结构HL7v3对SNOMEDCT之支援数据型态CD(CodeDescription)可以配合SNOMED之描述。NameTypeDescriptioncodeSTTheplaincodesymboldefinedbythecodesystem.Forexample,784.0isthecodesymboloftheICD-9code784.0forheadache.codeSystemUIDSpecifiesthecodesystemthatdefinesthecode.codeSystemNameSTThecommonnameofthecodingsystem.codeSystemVersionSTIfapplicable,aversiondescriptordefinedspecificallyforthegivencodesystem.displayNameSTAnameortitleforthecode,underwhichthesendingsystemshowsthecodevaluetoitsusers.originalTextEDThetextorphraseusedasthebasisforthecoding.translationSETCDAsetofotherconceptdescriptorsthattranslatethisconceptdescriptorintoothercodesystems.qualifierLISTCRSpecifiesadditionalcodesthatincreasethespecificityofthetheprimarycode.HL7v3对SNOMEDCT之支援codecodeSystem=2.16.840.1.113883.6.96code=195967001displayName=asthmaqualifiernamecode=246112005displayName=severity/valuecode=24484000displayName=severe//qualifier/codeCDAR2之临床描述0..*clinicalStatemententrytypeCode*:x_ActRelationshipEntrycontextConductionInd*:BL[1..1]true0..*externalActChoicetypeCode*:=x_ActRelationshipExternalReferenceseperatableInd:BL[0..1]referenceObservationclassCode*:=OBSmoodCode*:=x_ActMoodDocumentObservationid:SETII[0..*]code*:CDCWE[1..1]=ObservationTypenegationInd:BL[0..1]derivationExpr:ST[0..1]text:ED[0..1]statusCode:CSCNE[0..1]=ActStatuseffectiveTime:IVLTS[0..1]priorityCode:CECWE[0..1]=ActPriorityrepeatNumber:IVLINT[0..1]languageCode:CSCNE[0..1]=HumanLanguagevalue:ANY[0..1]interpretationCode:SETCECNE[0..*]methodCode:SETCECWE[0..*]targetSiteCode:SETCDCWE[0..*]ObservationMediaclassCode*:=OBSmoodCode*:=EVNid:SETII[0..*]languageCode:CSCNE[0..1]=HumanLanguagevalue*:ED[1..1]RegionOfInterestclassCode*:=ROIOVLmoodCode*:=EVNid*:SETII[1..*]code*:CSCNE[1..1]=ROIOverlayShapevalue*:LISTINT[1..*]SubstanceAdministrationclassCode*:=SBADMmoodCode*:=x_DocumentSubstanceMoodid:SETII[0..*]code:CDCWE[0..1]=SubstanceAdministrationActCodenegationInd:BL[0..1]text:ED[0..1]statusCode:CSCNE[0..1]=ActStatuseffectiveTime:GTS[0..1]priorityCode:CECWE[0..1]=ActPriorityrepeatNumber:IVLINT[0..1]routeCode:CECWE[0..1]=RouteOfAdministrationapproachSiteCode:SETCDCWE[0..*]=ActSitedoseQuantity:IVLPQ[0..1]rateQuantity:IVLPQ[0..1]maxDoseQuantity:RTOPQ,PQ[0..1]administrationUnitCode:CECWE[0..1]=AdministrableDrugFormSupplyclassCode*:=SPLYmoodCode*:=x_DocumentSubstanceMoodid:SETII[0..*]code:CDCWE[0..1]=ActCodetext:ED[0..1]statusCode:CSCNE[0..1]=ActStatuseffectiveTime:GTS[0..1]priorityCode:SETCECWE[0..*]=ActPriorityrepeatNumber:IVLINT[0..1]independentInd:BL[0..1]quantity:PQ[0..1]expectedUseTime:IVLTS[0..1]ProcedureclassCode*:=PROCmoodCode*:=x_DocumentProcedureMoodid:SETII[0..*]code:CDCWE[0..1]negationInd:BL[0..1]text:ED[0..1]statusCode:CSCNE[0..1]=ActStatuseffectiveTime:IVLTS[0..1]priorityCode:CECWE[0..1]=ActPrioritylanguageCode:CSCNE[0..1]=HumanLangua