SIST EN 1828:2003

2003-01.Slovenski inštitut za standardizacijo. Razmnoževanje celote ali delov tega standarda ni dovoljeno.Zdravstvena informatika – Kategorijske strukture za klasifikacijske in kodirne sisteme kirurških postopkovMedizinische Informatik - Struktur zur Klassifikation und Kodierung chirurgischer ProzedurenInformatique de santé - Structure catégorielle pour les classifications et systemes de codage des interventions chirurgicalesHealth informatics - Categorial structure for classifications and coding systems of surgical procedures35.240.80Uporabniške rešitve IT v zdravstveni tehnikiIT applications in health care technology35.040Nabori znakov in kodiranje informacijCharacter sets and information codingICS:Ta slovenski standard je istoveten z:EN 1828:2002SIST EN 1828:2003en01-oktober-2003SIST EN 1828:2003SLOVENSKI
STANDARD



SIST EN 1828:2003



EUROPEAN STANDARDNORME EUROPÉENNEEUROPÄISCHE NORMEN 1828May 2002ICS 35.240.80English versionHealth informatics - Categorial structure for classifications andcoding systems of surgical proceduresInformatique de santé - Structure catégorielle pour lesclassifications et systèmes de codage des interventionschirurgicalesMedizinische Informatik - Kategoriale Struktur fürKlassifikationen und Kodierungssyteme für chirurgischeProzedurenThis European Standard was approved by CEN on 11 April 2002.CEN members are bound to comply with the CEN/CENELEC Internal Regulations which stipulate the conditions for giving this EuropeanStandard the status of a national standard without any alteration. Up-to-date lists and bibliographical references concerning such nationalstandards may be obtained on application to the Management Centre or to any CEN member.This European Standard exists in three official versions (English, French, German). A version in any other language made by translationunder the responsibility of a CEN member into its own language and notified to the Management Centre has the same status as the officialversions.CEN members are the national standards bodies of Austria, Belgium, Czech Republic, Denmark, Finland, France, Germany, Greece,Iceland, Ireland, Italy, Luxembourg, Malta, Netherlands, Norway, Portugal, Spain, Sweden, Switzerland and United Kingdom.EUROPEAN COMMITTEE FOR STANDARDIZATIONCOMITÉ EUROPÉEN DE NORMALISATIONEUROPÄISCHES KOMITEE FÜR NORMUNGManagement Centre: rue de Stassart, 36
B-1050 Brussels© 2002 CENAll rights of exploitation in any form and by any means reservedworldwide for CEN national Members.Ref. No. EN 1828:2002 ESIST EN 1828:2003



EN 1828:2002 (E)2ContentspageForeword.3Introduction.41Scope.52Terms and definitions.53Concept categories.84Types of modifier.105Semantic links.106Combinatorial Rules.117Concept Diagram.13Bibliography .14SIST EN 1828:2003



EN 1828:2002 (E)3ForewordThis document (EN 1828:2002) has been prepared by Technical Committee CEN/TC 251, "Health informatics", thesecretariat of which is held by SIS.This European Standard shall be given the status of a national standard, either by publication of an identical text orby endorsement, at the latest by November 2002, and conflicting national standards shall be withdrawn at the latestby November 2002.This document supersedes ENV 1828:1995.According to the CEN/CENELEC Internal Regulations, the national standards organizations of the followingcountries are bound to implement this European Standard: Austria, Belgium, Czech Republic, Denmark, Finland,France, Germany, Greece, Iceland, Ireland, Italy, Luxembourg, Malta, Netherlands, Norway, Portugal, Spain,Sweden, Switzerland and the United Kingdom.SIST EN 1828:2003



EN 1828:2002 (E)4IntroductionThe definition of a surgical procedure is considered to be an impossible task for there are neither specific criteria tointentionally define it nor specific criteria to define the limit between what is a surgical procedure and what is notsuch a procedure.In this standard, classifications and coding systems of surgical are defined in the following way:A classification or a coding system that defines itself as a classification or a coding system of surgical proceduresand considers that it deals with surgical procedures. It is the responsibility of such a classification or coding systemto define its own content and therefore what is being considered as a surgical procedure.The main reason prompting the preparation of such a European Standard is that surgical procedures are coded fora wide range of purposes. For example, being incorporated as an integral part of a computerised healthcare record,for use in discharge summary information, for clinical research, per review, quality assurance, reimbursement,workload assessment, resource management, utilisation comparisons, public health management andepidemiological surveys. Unlike diagnoses for which the International Classification of Diseases (ICD) is anaccepted international de facto standard, there are at least as many coding systems for surgical procedures ascountries in Europe and, very often, several such coding systems for different purposes or for different surgicaldisciplines in each country. This hampers the exchange of meaningful health information and can increase theworkload of health professionals who may have to code each procedure more than once and of national orspecialised coding centres, which develop and update so many coding systems.ENV 1828 started by identifying the concepts underlying existing procedure classifications within and outsideEurope and also the natural language used in surgical reports. It defined the conceptual structure that contains thedefinition of a set of concepts and the internal relations that combine them into a concept system. It was widelytested in national and European projects, as well as outside Europe in Australia and Canada.The present European Standard is an extension of the pre-standard to the minimal computer based conceptsystem for surgical procedures. This should allow the user of a computerised health record to express himself in hisusual professional and national language but generate as outputs standard coding systems compliant with thecategorial structure. Several of the definitions of basic terms from the ISO/TC 37 work has been updated to themost recent version of ISO 1087-1:2000.SIST EN 1828:2003



EN 1828:2002 (E)51 ScopeThis European Standard specifies the characteristics of a categorial structure and the combinatorial rules requiredfor compliance, in order to support the exchange of meaningful surgical procedure information between differentnational classifications or coding systems of surgical procedures using different national languages within Europe.This standard is applicable to:— organisations involved with the development or maintenance of classifications and coding systems for medicalprocedures namely for multipurpose coding systems on a national or international level— organisations developing and maintaining software tools allowing natural clinical language expressions analysis,generation and mapping to the main existing classifications of surgical procedures.The standard has been developed for use as an integrated part of computer-based applications and for theelectronic healthcare record. It would be of limited value for manual use. The standard itself is not suitable for orintended for use by, the individual clinician or hospital administrator. It is not the purpose of this standard tostandardise the end user classification or to conflict with the concept systems embedded in national practice andlanguages.This standard is applicable to surgical procedures in all surgical disciplines.2Terms and definitionsFor the purposes of this European Standard, the following terms and definitions apply.2.1associative relationpragmatic relationpragmatic relation between two concepts (2.7) having a non-hierarchical thematic connection by virtue ofexperienceNOTEAn associative relation exists between the concepts (2.7) ‘education’ and ‘teaching’, ‘baking and ‘oven’ [ISO 1087-1]2.2categorial structurereduced system of concepts to describe the organisation of the semantic categories in a particular system ofconcepts for development, maintenance and application of terminological systemsNOTEAdapted from ENV 122642.3characteristicabstraction of a property of an object (2.17) or a set of objectsNOTECharacteristics are used for describing concepts (2.7)[ISO 1087-1]2.4classificationterminological concept system connected by generic relationsSIST EN 1828:2003



EN 1828:2002 (E)62.5combinatorial rulerule which governs the construction of a terminological phrase2.6comprehensive conceptconcept (2.7) in a partitive relation (2.13) viewed as the whole [ISO 1087-1]2.7conceptunit of knowledge created by a unique combination of characteristics (2.3)NOTEConcepts are not necessarily bound to particular languages. They are, however, influenced by the social or culturalbackground often leading to different categorizations.[ISO 1087-1]2.8concept categoryset of thematically related concepts 2.9concept systemsystem of conceptsset of concepts (2.7) structured according to the relations among them [ISO 1087-1]2.10delimiting characteristicessential characteristic (2.12) used for distinguishing a concept (2.7) from related concepts (2.7)NOTEThe delimiting characteristic support for the back may be used for distinguishing the concepts (2.7) ‘stool’ and ‘chair’[ISO 1087-1]2.11designationdesignatorrepresentation of a concept (2.7) by a sign which denotes itNOTEIn terminology work three types of designations are distinguished: symbols, appellations and terms.2.12essential characteristiccharacteristic (2.3) which is indispensable to understanding a concept (2.7) [ISO 1087-1]2.13generic conceptconcept (2.7) in a generic relation (2.14) having the narrower intension (2.15) [ISO 1087-1]SIST EN 1828:2003



EN 1828:2002 (E)72.14generic relationrelation between two concepts (2.7) where the intension (2.15) of one of the concepts (2.7) includes that of theother concept (2.7) and at least one additional delimiting characteristic (2.10) NOTEA generic relation exists between the concepts (2.7) ‘word’ and ‘pronoun’, ‘vehicle’ and ‘car’, ‘person’ and ‘child’. [ISO1087-1]2.15intensionset of characteristics (2.3) which makes up the concept (2.7) [ISO 1087-1]2.16modifierterm which refers to characteristics that can be added to a super-ordinate concept to form a subordinate concept ina generic relationEXAMPLE "right" in "right side".2.17objectanything perceivable or conceivableNOTEObjects can be material (e.g. an engine, a sheet of paper, a diamond), immaterial (e.g. conversion ratio, aproject plan) or imagined (e.g. a unicorn). [ISO 1087-1]2.18partitive conceptconcept (2.7) in a partitive relation (2.19) viewed as one of the parts making up the whole [ISO 1087-1]2.19partitive relationrelation between two concepts (2.7) where one of the concepts (2.7) constitutes the whole and the other concept(2.7) a part of the wholeNOTEA partitive relation exists between the concepts (2.7) ‘week’ and ‘day’, ‘molecule’ and ‘atom’. [ISO 1087-1]2.20semantic linkterminological phrase describing the interdependence between two related conceptsNOTE the semantic link usually describes an associative relation.EXAMPLE "by means of" and "from" in "remove polyp from colon by means of endoscope".2.21specific conceptconcept (2.7) in a generic relation (2.14) having the broader intension (2.15) [ISO 1087-1]2.22subordinate conceptnarrower conceptconcept (2.7) which is either a specific concept (2.21) or a partitive concept (2.18) [ISO 1087-1]SIST EN 1828:2003



EN 1828:2002 (E)82.23superordinate conceptbroader conceptconcept (2.7) which is either a generic concept (2.13) or a comprehensive concept (2.6) [ISO 1087-1]2.24termverbal designation (2.11) of a general concept in a specific subject fieldNOTEA term can contain symbols and can have variants, e.g., different forms of spelling.[ISO 1087-1]2.25terminological phraseword combination containing at least one term and a number of other lexical items the choice of which beingrestricted by the term in questionEXAMPLE "to carry out a surgical deed".3Concept categories3.1surgical deeddeed which can be done by the operator to the patient's body during the surgi
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