Medical Problem and Document Model for Natural Language Understanding

摘要

We are developing tools to help maintain a complete, accurate and timely problem list within a general purpose Electronic Medical Record system. As a part of this project, we have designed a system t o automatically retrieve medical problems from free-text documents. Here we describe an information model based on XML (eXtensible Markup Language) and compliant with the CDA (Clinical Document Architecture). This model is used to ease the exchange of clinical data between the Natural Language Understanding application that retrieves potential problems from narrative document, and the problem list management application.