Over deze norm
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.
||Mediscyhe informatica - Conceptueel raamwerk voor patientenonderzoek en problemen met terminologie
||Health informatics - Conceptual framework for patient findings and problems in terminologies