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.
1.2 Target groups
The target groups for this Technical Specification are:
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developers of terminology systems concerning patient findings and problems;
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developers of information systems that require a structured framework of concepts to facilitate implementation;
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IT specialists, analysts and epidemiologists who require common models of knowledge to facilitate analysis of current and legacy data from one or more information systems;
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clinicians and coders to provide greater consistency in structure and organization when entering and retrieving data using one or more terminology systems;
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managers and administrative personnel in providing a benchmark by which to judge terminology solutions: as to whether the potential options will deliver compatibility with legacy data and future proofing to emerging terminology products.
1.3 Topics considered outside the scope
Topics considered outside the scope of this Technical Specification include:
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a comprehensive categorial structure for clinical findings;
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laboratory findings (including biochemical and histological results);
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signal findings (including the output from imaging and electrophysiological tests);
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social findings;
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the absence of findings, e.g. absent bowel sounds, the absence of a knee reflex, are not included within this Technical Specification as it might prejudice subsequent attempts at standardizing the modelling of such instances;
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an exhaustive list of all possible characterizing concepts that could be used to describe clinical findings.