CIMI_Clinical.ClinicalStatement

Class ClinicalStatement

Documentation:

A special type of information entry consisting of a topic and a context. 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
• • Independent
• • • Content
• • • • Entry
• • • • • InformationEntry
• • • • • • ClinicalStatement

Descendants:

Property Summary

Properties

Property Name	Type and Description	Existence	Cardinality
topic	T What the statement is about, e.g., the kind of finding or action. The range of this attribute is a structure (StatementTopic) rather than a value set. For instance, if the 'topic' attribute's meaning is bound to 'ProcedureTopic, then the topic must be a specialization of ProcedureTopic. This attribute aligns with the SNOMED CT 'Associated finding (attribute)' (SCTID: 246090004) and 'Associated procedure (attribute)' (SCTID: 363589002).	0..1	N/A
context	C 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 (SWEC) 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
encounter	DetailedEncounter Encounter associated with this clinical statement.	0..1	N/A

Properties inherited from class InformationEntry

identifier, subjectOfInformation, additionalText, recordStatus, recorded, signed, cosigned, verified

Properties inherited from class Entry

Properties inherited from class Content

Properties inherited from class Independent

Properties inherited from class Locatable

archetype_node_id, name, archetype_details