The NOTE table captures unstructured information that was recorded by a provider about a patient in free text notes on a given date.
NOTE表記錄的是貢獻者在某一日期為居民記下的自由文本信息記錄。
| Field | Required | Type | Description | 字段 | 描述 |
|---|---|---|---|---|---|
| note_id | Yes | integer | A unique identifier for each note. | 文本記錄-標識符 | 每個文本記錄的唯一標識符。 |
| person_id | Yes | integer | A foreign key identifier to the Person about whom the Note was recorded. The demographic details of that Person are stored in the PERSON table. | 居民-標識符 | 外鍵，該文本記錄所對應(yīng)的居民標識符。該居民的人口統(tǒng)計詳細信息存儲在PERSON表中。 |
| note_event_id | No | integer | A foreign key identifier to the event (e.g. Measurement, Procedure, Visit, Drug Exposure, etc) record during which the note was recorded. | 文本記錄-事件-標識符 | 外鍵，指該次文本記錄對應(yīng)的事件的標識符（例如這些事件：檢查檢驗，操作，就診，藥物暴露等）。 |
| note_event_field_concept_id | No | integer | A foreign key to the predefined Concept in the Standardized Vocabularies reflecting the field to which the note_event_id is referring. | 文本記錄-事件-字段-概念-標識符 | 外鍵，指向標準詞匯表中預(yù)定義的概念，反映了note_event_id，即記錄所對應(yīng)的事件的字段。 |
| note_date | No | date | The date the note was recorded. | 文本記錄-日期 | 文本記錄的日期 |
| note_datetime | Yes | datetime | The date and time the note was recorded. | 文本記錄-日期時間 | 記下文本記錄的日期和時間。 |
| note_type_concept_id | Yes | integer | A foreign key to the predefined Concept in the Standardized Vocabularies reflecting the type, origin or provenance of the Note. These belong to the 'Note Type' vocabulary | 文本記錄-類型-概念-標識符 | 外鍵，指向標準詞匯表中預(yù)定義概念，反映了文本記錄的類型、來源或出處。這些屬于'Note Type'詞匯表 |
| note_class_concept_id | Yes | integer | A foreign key to the predefined Concept in the Standardized Vocabularies reflecting the HL7 LOINC Document Type Vocabulary classification of the note. | 文本記錄-類別-概念-標識符 | 外鍵，標準詞匯表中預(yù)定義概念，對應(yīng)HL7 LOINC文檔類型字典中該文本記錄的類型。 |
| note_title | No | varchar(250) | The title of the Note as it appears in the source. | 文本記錄-標題 | 源數(shù)據(jù)中該文本記錄的標題 |
| note_text | Yes | varchar(MAX) | The content of the Note. | 文本記錄-文本 | 文本記錄的文本內(nèi)容 |
| encoding_concept_id | Yes | integer | A foreign key to the predefined Concept in the Standardized Vocabularies reflecting the note character encoding type | 編碼-概念-標識符 | 外鍵，標識了標準詞匯表中預(yù)定義概念中，文本記錄的字符編碼類型 |
| language_concept_id | Yes | integer | A foreign key to the predefined Concept in the Standardized Vocabularies reflecting the language of the note | 語言-概念-標識符 | 外鍵，標識了標準詞匯表中預(yù)定義概念中，文本記錄文本所使用的自然語言類型， |
| provider_id | No | integer | A foreign key to the Provider in the PROVIDER table who took the Note. | 貢獻者-標識符 | 外鍵，指向PROVIDER表中產(chǎn)生該文本記錄的貢獻者。 |
| visit_occurrence_id | No | integer | A foreign key to the Visit in the VISIT_OCCURRENCE table when the Note was taken. | 就診-發(fā)生-標識符 | 外鍵，指向該次就診的VISIT_OCCURRENCE表 |
| visit_detail_id | No | integer | A foreign key to the Visit in the VISIT_DETAIL table when the Note was taken. | 就診-詳情-標識符 | 外鍵。指向該次就診的VISIT_DETAIL表 |
| note_source_value | No | varchar(50) | The source value associated with the origin of the Note | 文本記錄-源-值 | 與該次文本記錄關(guān)聯(lián)的源數(shù)據(jù)的值 |
共識
| No. | Convention Description | 共識 |
|---|---|---|
| 1 | The NOTE table contains free text (in ASCII, or preferably in UTF8 format) taken by a healthcare Provider. | NOTE表包含醫(yī)療服務(wù)貢獻者文本記錄的自由文本（ASCII格式，最好是UTF8格式）。 |
| 2 | The Visit during which the note was written is recorded through a reference to the VISIT_OCCURRENCE table. This information is not always available. | 文本記錄所關(guān)聯(lián)的就診信息，是通過對VISIT_OCCURRENCE表的引用來記錄的。此信息并非始終可用。 |
| 3 | The Provider making the note is recorded through a reference to the PROVIDER table. This information is not always available. | 記下文本記錄的貢獻者的信息，是通過對PROVIDER表的引用進行記錄的。此信息并非始終可用。 |
| 4 | The type of note_text is CLOB or varchar(MAX) depending on RDBMS | note_text的類型是CLOB或varchar（MAX），具體取決于RDBMS關(guān)系型數(shù)據(jù)庫 |
| 5 | NOTE_CLASS_CONCEPT_ID is a foreign key to the CONCEPT table to describe a standardized combination of five LOINC axes (role, domain, setting, type of service, and document kind). See below for description. | NOTE_CLASS_CONCEPT_ID是指向CONCEPT表的外鍵，用于描述五個LOINC軸（角色，類型，設(shè)置，服務(wù)類型和文檔類型）的標準化組合。請參閱下面的說明。 |
將臨床文件映射到臨床記錄本體論（CDO）和標準術(shù)語
HL7 / LOINC CDO是標準化統(tǒng)一記錄文檔命名標準，用于支持一系列用例：檢索，整理，顯示和交流。CDO指導(dǎo)臨床記錄的LOINC代碼的創(chuàng)建，用5個維度注釋每個文檔：
文檔類型：在宏觀層面描述臨床記錄文檔的一般結(jié)構(gòu)（例如麻醉知情同意）
服務(wù)類型：標識服務(wù)或其他行為的類型（例如評估，咨詢或總結(jié)）。時間序列的概念例如：開始（入院）至結(jié)束（出院）都包含在該概念軸中。例如出院宣教。
設(shè)置：設(shè)置是CMS的定義的擴展（例如住院患者，門診患者）（原文對CMS未做注釋，故暫無法翻譯）
專業(yè)域（SMD）：標識記錄所對應(yīng)的亞專業(yè)的概念所屬域（例如麻醉學(xué)）
職務(wù)：標識該記錄信息的采集者（作者）的培訓(xùn)或?qū)I(yè)水平，但不分專業(yè)或亞專業(yè)（例如醫(yī)師）
Mapping of clinical documents to Clinical Document Ontology (CDO) and standard terminology
HL7/LOINC CDO is a standard for consistent naming of documents to support a range of use cases: retrieval, organization, display, and exchange. It guides the creation of LOINC codes for clinical notes. CDO annotates each document with 5 dimensions:
- Kind of Document: Characterizes the general structure of the document at a macro level (e.g. Anesthesia Consent)
- Type of Service: Characterizes the kind of service or activity (e.g. evaluations, consultations, and summaries). The notion of time sequence, e.g., at the beginning (admission) at the end (discharge) is subsumed in this axis. Example: Discharge Teaching.
- Setting: Setting is an extension of CMS?s definitions (e.g. Inpatient, Outpatient)
- Subject Matter Domain (SMD): Characterizes the subject matter domain of a note (e.g. Anesthesiology)
- Role: Characterizes the training or professional level of the author of the document, but does not break down to specialty or subspecialty (e.g. Physician)
這5個維度的每個組合都匯總為唯一的LOINC代碼。
- 根據(jù)CDO要求，正確標識記錄文檔需要5個維度中的2個：文檔類型和其他4個維度中的任何一個。
- 然而，并非所有CDO維度的排列都必然會生成現(xiàn)有的LOINC代碼。2 HL7 / LOINC的貢獻者們致力于為每個新遇到的CDO維度組合建立新的LOINC代碼。
- 詞匯表中存在的完整文檔概念本體實在太廣泛，故無法在此列出，但可以通過ATHENA工具進行搜索，從“LOINC文檔本體 - 服務(wù)類型和文檔類型”開始，遍歷“Is a'/'Subsumes'關(guān)系層次結(jié)構(gòu)。
Each combination of these 5 dimensions rolls up to a unique LOINC code.
- According to CDO requirements, only 2 of the 5 dimensions are required to properly annotate a document: Kind of Document and any one of the other 4 dimensions.
- However, not all the permutations of the CDO dimensions will necessarily yield an existing LOINC code.2 HL7/LOINC workforce is committed to establish new LOINC codes for each new encountered combination of CDO dimensions.
- The full document ontology as it exists in the Vocabulary is too extensive to list here, but it is possible to explore through the ATHENA tool starting with the 'LOINC Document Ontology - Type of Service and Kind of Document' by walking through the 'Is a'/'Subsumes' relationship hierarchies.
本系列在介紹目前世界上最適用于臨床科研+衛(wèi)生經(jīng)濟學(xué)的標準醫(yī)療大數(shù)據(jù)格式（未經(jīng)嚴謹考證，但有相關(guān)研究發(fā)表在專業(yè)期刊上），儼然是真實世界研究方案里面最接進成熟的基礎(chǔ)建設(shè)方案。感興趣的介紹請移步B站觀看視頻。
OHDSI——觀察性健康醫(yī)療數(shù)據(jù)科學(xué)與信息學(xué)，是一個世界性的公益型非盈利研究聯(lián)盟，主要研究全方位醫(yī)學(xué)大數(shù)據(jù)分析的開源解決方案，旨在通過大規(guī)模數(shù)據(jù)分析和挖掘來提升臨床醫(yī)學(xué)數(shù)據(jù)價值，實現(xiàn)跨學(xué)科、跨行業(yè)的多方合作。目前，目前，已有來自美國、加拿大、澳大利亞、英國等幾十個國家地區(qū)的上百個組織機構(gòu)，高校，醫(yī)院和公司企業(yè)參與了OHDSI全球協(xié)作網(wǎng)絡(luò)，如斯坦福、哈佛、杜克大學(xué)醫(yī)學(xué)院，強生、諾華、甲骨文、IBM公司，擁有超過6億人口的臨床數(shù)據(jù)規(guī)模，累計協(xié)作研究發(fā)表了上百篇論文。
我們在這里邀請國內(nèi)對相關(guān)工作感興趣、愿共同學(xué)習的好學(xué)人士參與到中文興趣小組，互通有無，一起彌補跨行業(yè)、跨學(xué)科的知識積累。前期主要以對OHDSI在github上的開源工作進行翻譯、交流、學(xué)習為主，并會對醫(yī)療大數(shù)據(jù)、醫(yī)學(xué)統(tǒng)計學(xué)、生物信息學(xué)等學(xué)科知識建立學(xué)習互助、互督的機制。有興趣的請看文檔，微信群二維碼在內(nèi)：OHDSI中文興趣小組共識&OHDSI介紹
OHDSI秉持開源、開放的宗旨，加快全球醫(yī)學(xué)數(shù)據(jù)研究的步伐，本文內(nèi)容原創(chuàng)來自Github（https://github.com/OHDSI/CommonDataModel/wiki），若有利益沖突，請在本頁面留言，真-侵刪。
