Health informatics. Conceptual framework for patient findings and problems in terminologies
Health informatics. Conceptual framework for patient findings and problems in terminologies
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1 Scope
1.1 Main purpose The purpose of this Technical Specification is to specify a categorial structure , within the subject field of patient findings and problems, by defining a set of common domain constraint s for use within terminological systems including a classification, coding scheme, coding system, reference terminology and clinical terminology. Clinical findings are concept s that are recorded in clinical records and can describe any state observed directly or indirectly concerning a patient and their relationship with the environment. This Technical Specification is focused on a sub-population of these findings concerning in vivo descriptions of state (structure and function) directly related to the patient. This class of concept s includes:
— diseases, which may be defined as a state caused by a known or assumed pathological process impairing the normal physiological function and/or anatomical structure affecting all or part of a patient, where a specific pathological change is caused by a defined mechanism;
— findings of state or function (including normal findings) observed directly relating to a patient.
This Technical Specification describes a concept system detailing a domain constraint of sanctione...
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