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When patient data is recorded in an electronic health record, the clinical meaning is captured through a combination of the values that are stored and the information structure in which they are stored. To understand clinical data, it is important to understand the close relationship between the information model and the terminology. The terminology provides clinical meaning through its concepts whose codes are recorded in the information model. The information model, in turn augments the meaning of these codes with additional context, qualification, and structure to build the full meaning.

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Information Models

  • 章节

  • 发表日期：

    2025年

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  • Linda Bird

摘要

When patient data is recorded in an electronic health record, the clinical meaning is captured through a combination of the values that are stored and the information structure in which they are stored. To understand clinical data, it is important to understand the close relationship between the information model and the terminology. The terminology provides clinical meaning through its concepts whose codes are recorded in the information model. The information model, in turn augments the meaning of these codes with additional context, qualification, and structure to build the full meaning.