1. Scope
1.1 This specification covers the documentation of the principal notions necessary and sufficient to assign value to a controlled health vocabulary. This specification will serve as a guide for governments, funding agencies, terminology developers, terminology integration organizations, and the purchasers and users of controlled health terminology systems working toward improved terminological development and recognition of value in a controlled health vocabulary. It is applicable to all areas of health care about which information is kept or utilized. It is intended to complement and utilize those notions already identified by other national and international standards bodies.
1.2 This specification will provide vocabulary developers and authors with the guidelines needed to construct useful, maintainable controlled health vocabularies. These tenets do not attempt to specify all of the richness that can be incorporated into a health terminology. However this specification does specify the minimal requirements, which, if not adhered to, will ensure that the vocabulary will have limited generalizability and will be very difficult, if not impossible, to maintain. This specification will provide terminology developers with a sturdy starting point for the development of controlled health vocabularies. This foundation serves as the basis from which vocabulary developers will build robust, large-scale, reliable and maintainable terminologies.
1.3 This specification explicitly does not refer to classifications or coding systems (for example, a simple list of pairs of rubrics and codes) that are not designed to be used clinically.
2. Referenced Documents
E1238 Specification for Transferring Clinical Observations Between Independent Computer Systems
E1239 Guide for Description of Reservation/Registration-Admission, Discharge, Transfer (R-ADT) Systems for Automated Patient Care Information Systems
E1284 Guide for Construction of a Clinical Nomenclature for Support of Electronic Health Records
E1384 Guide for Content and Structure of the Electronic Health Record (EHR)
E1633 Specification for Coded Values Used in the Electronic Health Record
E1712 Specification for Representing Clinical Laboratory Procedure and Analyte Names
EN 12017 Medical Informatics-Vocabulary
EN 12264 Medical Informatics-Categorical Structure of Syntax of Concepts-Model for Representation of Semantics
ICD-9-CM
IS 1087-1 Terminology-Vocabulary-Part 1: Theory and Application
IS 1087-2 Terminology-Vocabulary-Part 2: Computer Applications
IS 11179-3 Terminology-Data Registries
IS 12200 Terminology-Computer Applications-Machine Readable Terminology Interchange Format
IS 12620 Terminology-Computer Applications-Data Categories
IS 15188 Project Management for Terminology Standardization
IS 2382-4 Information Technology-Vocabulary-Part 4: Organization of Data
IS 704 Principles and Methods of Terminology
ISO TR 9789 Guidelines for the Organization and Representation of Data Elements for Data Interchange-Coding Methods and Principles
ISO/DIS 860 International Harmonization of Concepts and Terms
Index Terms
ICS Number Code 01.040.13
DOI: 10.1520/E2087-00

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