A tagging system for section headings in a CEN standard on patient record.

CEN is developing a series of standards for transmission of patient records. We present here preliminary results to produce a standard on section headings in record systems. Each record system uses its own scheme of headings, depending on specialty, National regulations and tasks; users cannot accept a unique, standard scheme. Enumerating all possible headings in all National languages is not necessary for a safe and faithful transmission of records. The focus of CEN standard is shifting from the headings to a system of tags that can be tied to them. We want to convey just the crucial properties to assure correct data handling by receivers. Our tagging system is organized into 5 clusters: C0 Nature, i.e. tags to identify the nature of data; C1 Safety context, i.e. essential tags that convey the main context of data; C2 Interpretation, i.e. tags about interpretation of data in the original context by the original user; C3 Intention, i.e. additional tags to make explicit the links that reveal sender's intentions and goals; C4 Organization, i.e. further tags to show the organization of the original record. Although tags were conceived for messages, they should be present in local systems since data generation. In fact, tags can be used to organize data within a record and allow for multiple views, without imposing a unique, fixed structure to the record.