International Organization for Standardization

Health informatics — Conceptual framework for patient findings and problems in terminologies - First Edition
 N TS 22789

Annotation

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:

— 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 sanctioned characteristics each composed of a semantic link and an applicable characterizing category.

The potential uses for this conceptual framework are to:

— support developers of new terminology systems concerning patient findings and problems;