CIMI_Clinical.ClinicalStatement

Class BaseClinicalStatement

Documentation:

The documentation of clinical information about a subject of information such as a patient or a relative of the patient, asserted by a particular source, recorded, and potentially verified. The ClinicalStatement class provides the core pattern for more specific clinical statement archetypes, such as a statement that a finding has been found in a patient or that a procedure has been proposed by a clinical decision support system. The ClinicalStatement pattern defines the core attributes common to most clinical statements and specifies a composition pattern that encourage model component reuse and better alignment with the SNOMED CT Concept Model. A clinical statement is composed of the StatementTopic class (grouping of attributes for capturing information about a procedure or a clinical finding) and the StatementContext class (grouping of attributes providing the context for the statement topic such as whether a procedure was performed, requested, not performed or whether a finding is suspected present or absent in the patient). At the archetype level, the topic and context components are coordinated to form the clinical statement. For instance, the composition of the ProcedureTopic with the NotPerformed context indicates that the given procedure was not performed.

Ancestors:

• LOCATABLE
• • CONTENT
• • • ENTRY
• • • • BaseClinicalStatement

Descendants:

• CompoundClinicalStatement,
• IndivisibleClinicalStatement

Property Summary

Properties

Property Name	Type and Description	Existence	Cardinality
key	CODED_TEXT The 'key' attribute is an optional attribute allowing the coding of some of the information represented by the clinical statement. The range of this attribute (i.e., allowable codes assigned as a value for this attribute) must derive from and conform with the SNOMED CT Situation with Explicit Context (SWEC) concept hierarchies defined in SNOMED CT. Note that this attribute may consist of precoordinated codes (not recommended) or SNOMED CT expressions.	0..1	N/A
identifier	List<IDENTIFIER> The unique identifier(s) of this clinical statement. It must be entered if user wants it returned as part of any output (e.g., a wound number), otherwise it will be auto-generated, if needed, by the system serving the record. An identifier does not need to be the actual identifier of the source system.	0..1	0..*
subjectOfInformation	SubjectOfInformation The entity being described by this statement. The entity may be animate (a patient, a relative of the patient, a veterinary patient, a cohort) or inanimate (a well, a geographical location). The subject of information is constrained in archetypes. This attribute aligns with the SNOMED CT Situation with Explicit Context (SWEC) and is bound to the SNOMED attribute: 'Subject relationship context (attribute)' (SCTID: 408732007).	0..1	N/A
topic	StatementTopic What the statement is about, e.g., the kind of finding or procedure asserted. Attribute aligns with the SNOMED CT Situation with Explicit Context (SWEC) Concept Model attributes 'Associated finding (attribute)' (SCTID: 246090004) and 'Associated procedure (attribute)' (SCTID: 363589002). The range of this attribute is a structure (StatementTopic) rather than a value set. The topic of the clinical statement must align with the range specified by the SWEC Concept Model. For instance, if the 'topic' attribute's meaning is bound to 'Associated finding', then the topic may not be a specialization of the Act statement topic.	0..1	N/A
context	StatementContext The ontological status of the statement, e.g., whether it exists, does not exist, is planned, etc. Attribute aligns with the SNOMED CT Situation with Explicit Context Concept Model context attributes 'Finding context (attribute)' (SCTID: 408729009) and 'Procedure context (attribute)' (SCTID: 408730004). The range of this attribute is a structure (StatementContext) rather than a value set. The context of the clinical statement must align with the range specified by the SWEC Concept Model. For instance, if the 'context' attribute's meaning is bound to 'Finding context', then the context may not be a specialization of the ActionContext statement context. Instead, it should be a specialization of the FindingContext statement context.	0..1	N/A
contextAttribution	Attribution The attribution for the given context such as the who, what, when, where, how (e.g., origination mode) responsible for proposing, planning, ordering and authorizing, etc... The contextAttribution attribute is intended to be constrained appropriately within CIMI archetypes.	0..1	N/A
contextStatusHistory	List<Attribution> A record of the states for an action in a specified action context, e.g., an order may evolve from draft to placed to in progress to completed or canceled. The use of Attribution rather than a simple code for status supports the consistent capture of additional metadata associated with the specified status. For instance, if the proposal was declined, who declined it, when was it declined, and so on ...	0..1	0..*
authored	Attribution Provenance information specific to the assertion being made (e.g., the author(s), when authored, the location where the assertion was made, etc...).	0..1	N/A
recorded	Attribution Provenance information specific to the recording of the clinical statement (e.g., when recorded, where recorded, etc...).	0..1	N/A
verified	Attribution Provenance information specific to the verification process associated with this statement (e.g., verifier, verification method, when verified, etc...).	0..1	N/A
signed	Attribution Provenance information specific to the signing of the clinical statement.	0..1	N/A
cosigned	List<Attribution> Provenance information specific to the cosigning of the clinical statement.	0..1	0..*
additionalText	List<Annotation> Unstructured notes appended to a clinical statement.	0..1	0..*
recordStatus	CODED_TEXT Concept indicating the state of this record. E.g., 'entered in error'.	0..1	N/A
originatingFrom	BaseClinicalStatement The encounter or episode of care from which this statement originates.	0..1	N/A
encounter	BaseClinicalStatement Encounter associated with this clinical statement.	0..1	N/A

Properties inherited from class ENTRY

Properties inherited from class CONTENT

Properties inherited from class LOCATABLE

archetype_node_id, name, archetype_details