The NOTE table captures unstructured information that was recorded by a provider about a patient in free text notes on a given date.
NOTE表记录的是贡献者在某一日期为居民记下的自由文本信息记录。
| Field | Required | Type | Description | 字段 | 描述 |
|---|---|---|---|---|---|
| note_id | Yes | integer | A unique identifier for each note. | 文本记录-标识符 | 每个文本记录的唯一标识符。 |
| 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-标识符 | 外键，该文本记录所对应的居民标识符。该居民的人口统计详细信息存储在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. | 文本记录-事件-标识符 | 外键，指该次文本记录对应的事件的标识符（例如这些事件：检查检验，操作，就诊，药物暴露等）。 |
| 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. | 文本记录-事件-字段-概念-标识符 | 外键，指向标准词汇表中预定义的概念，反映了note_event_id，即记录所对应的事件的字段。 |
| note_date | No | date | The date the note was recorded. | 文本记录-日期 | 文本记录的日期 |
| note_datetime | Yes | datetime | The date and time the note was recorded. | 文本记录-日期时间 | 记下文本记录的日期和时间。 |
| 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 | 文本记录-类型-概念-标识符 | 外键，指向标准词汇表中预定义概念，反映了文本记录的类型、来源或出处。这些属于'Note Type'词汇表 |
| 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. | 文本记录-类别-概念-标识符 | 外键，标准词汇表中预定义概念，对应HL7 LOINC文档类型字典中该文本记录的类型。 |
| note_title | No | varchar(250) | The title of the Note as it appears in the source. | 文本记录-标题 | 源数据中该文本记录的标题 |
| note_text | Yes | varchar(MAX) | The content of the Note. | 文本记录-文本 | 文本记录的文本内容 |
| encoding_concept_id | Yes | integer | A foreign key to the predefined Concept in the Standardized Vocabularies reflecting the note character encoding type | 编码-概念-标识符 | 外键，标识了标准词汇表中预定义概念中，文本记录的字符编码类型 |
| language_concept_id | Yes | integer | A foreign key to the predefined Concept in the Standardized Vocabularies reflecting the language of the note | 语言-概念-标识符 | 外键，标识了标准词汇表中预定义概念中，文本记录文本所使用的自然语言类型， |
| provider_id | No | integer | A foreign key to the Provider in the PROVIDER table who took the Note. | 贡献者-标识符 | 外键，指向PROVIDER表中产生该文本记录的贡献者。 |
| visit_occurrence_id | No | integer | A foreign key to the Visit in the VISIT_OCCURRENCE table when the Note was taken. | 就诊-发生-标识符 | 外键，指向该次就诊的VISIT_OCCURRENCE表 |
| visit_detail_id | No | integer | A foreign key to the Visit in the VISIT_DETAIL table when the Note was taken. | 就诊-详情-标识符 | 外键。指向该次就诊的VISIT_DETAIL表 |
| note_source_value | No | varchar(50) | The source value associated with the origin of the Note | 文本记录-源-值 | 与该次文本记录关联的源数据的值 |
共识
| No. | Convention Description | 共识 |
|---|---|---|
| 1 | The NOTE table contains free text (in ASCII, or preferably in UTF8 format) taken by a healthcare Provider. | NOTE表包含医疗服务贡献者文本记录的自由文本（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. | 文本记录所关联的就诊信息，是通过对VISIT_OCCURRENCE表的引用来记录的。此信息并非始终可用。 |
| 3 | The Provider making the note is recorded through a reference to the PROVIDER table. This information is not always available. | 记下文本记录的贡献者的信息，是通过对PROVIDER表的引用进行记录的。此信息并非始终可用。 |
| 4 | The type of note_text is CLOB or varchar(MAX) depending on RDBMS | note_text的类型是CLOB或varchar（MAX），具体取决于RDBMS关系型数据库 |
| 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表的外键，用于描述五个LOINC轴（角色，类型，设置，服务类型和文档类型）的标准化组合。请参阅下面的说明。 |
将临床文件映射到临床记录本体论（CDO）和标准术语
HL7 / LOINC CDO是标准化统一记录文档命名标准，用于支持一系列用例：检索，整理，显示和交流。CDO指导临床记录的LOINC代码的创建，用5个维度注释每个文档：
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文档类型：在宏观层面描述临床记录文档的一般结构（例如麻醉知情同意）
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服务类型：标识服务或其他行为的类型（例如评估，咨询或总结）。时间序列的概念例如：开始（入院）至结束（出院）都包含在该概念轴中。例如出院宣教。
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设置：设置是CMS的定义的扩展（例如住院患者，门诊患者）（原文对CMS未做注释，故暂无法翻译）
-
专业域（SMD）：标识记录所对应的亚专业的概念所属域（例如麻醉学）
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职务：标识该记录信息的采集者（作者）的培训或专业水平，但不分专业或亚专业（例如医师）
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)
这5个维度的每个组合都汇总为唯一的LOINC代码。
- 根据CDO要求，正确标识记录文档需要5个维度中的2个：文档类型和其他4个维度中的任何一个。
- 然而，并非所有CDO维度的排列都必然会生成现有的LOINC代码。2 HL7 / LOINC的贡献者们致力于为每个新遇到的CDO维度组合建立新的LOINC代码。
- 词汇表中存在的完整文档概念本体实在太广泛，故无法在此列出，但可以通过ATHENA工具进行搜索，从“LOINC文档本体 - 服务类型和文档类型”开始，遍历“Is a'/'Subsumes'关系层次结构。
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.
本系列在介绍目前世界上最适用于临床科研+卫生经济学的标准医疗大数据格式（未经严谨考证，但有相关研究发表在专业期刊上），俨然是真实世界研究方案里面最接进成熟的基础建设方案。感兴趣的介绍请移步B站观看视频。
OHDSI——观察性健康医疗数据科学与信息学，是一个世界性的公益型非盈利研究联盟，主要研究全方位医学大数据分析的开源解决方案，旨在通过大规模数据分析和挖掘来提升临床医学数据价值，实现跨学科、跨行业的多方合作。目前，目前，已有来自美国、加拿大、澳大利亚、英国等几十个国家地区的上百个组织机构，高校，医院和公司企业参与了OHDSI全球协作网络，如斯坦福、哈佛、杜克大学医学院，强生、诺华、甲骨文、IBM公司，拥有超过6亿人口的临床数据规模，累计协作研究发表了上百篇论文。
我们在这里邀请国内对相关工作感兴趣、愿共同学习的好学人士参与到中文兴趣小组，互通有无，一起弥补跨行业、跨学科的知识积累。前期主要以对OHDSI在github上的开源工作进行翻译、交流、学习为主，并会对医疗大数据、医学统计学、生物信息学等学科知识建立学习互助、互督的机制。有兴趣的请看文档，微信群二维码在内：OHDSI中文兴趣小组共识&OHDSI介绍
OHDSI秉持开源、开放的宗旨，加快全球医学数据研究的步伐，本文内容原创来自Github（https://github.com/OHDSI/CommonDataModel/wiki），若有利益冲突，请在本页面留言，真-侵删。
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