ISO/TS 22789:2010 PDF

Scope: 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.

ISO/TS 22789:2010 history

2010 ISO/TS 22789:2010 Health informatics - Conceptual framework for patient findings and problems in terminologies