Tuesday, April 5, 2011

The relationship between Documents, Sections and Clinical Statements

The content for a clinical document is specified using Sections and Clinical Statements as building blocks.

Each Clinical Document contains exactly one header. The content of the Header is defined by the US Realm Header Template.

Each Clinical Document contains one or more sections. The content of a section is defined by its Section Template.

Each Section contains zero or more Clinical Statements. Some Sections are “narrative only” and do not contain any Clinical Statements. The content of a Clinical Statement is defined by its Clinical Statement Template.

This approach allows each document that contains an Allergy Section to use the same rules for constructing that section.

This approach allows each section that contains a Procedure Activity to use the same rules for constructing that Clinical Statement.

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