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 constraints for use within terminological systems including a classification, coding scheme, coding system, reference terminology and clinical terminology.
Clinical findings are concepts 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 concepts includes:
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— 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;
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— 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 sanctioned characteristics each composed of a semantic link and an applicable characterizing category.
The potential uses for this conceptual framework are to:
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— support developers of new terminology systems concerning patient findings and problems;
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— support developers of new detailed content areas of existing terminology systems concerning patient findings and problems to ensure conformance;
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— facilitate the representation of patient findings and problems using a standard core model in a manner suitable for computer processing;
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— provide a conceptual framework for the generation of compositional concept representation of patient findings and problems;
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— facilitate the mapping and improved semantic correspondence between different terminologies by proposing a core specification for patient findings and problems;
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— provide a core model to describe the structure of patient findings and problems, and facilitate improved semantic correspondence with information models.