Clinical Findings with Explicit Context
Definition and Purpose
Clinical findings with explicit context refer to situations where the presence, absence, or uncertainty of a clinical finding is documented with additional contextual details. These concepts provide a clear understanding of the specific circumstances under which a clinical finding is relevant.
Attributes
Associated Finding : Links the situation to a relevant clinical finding or event.
For example, the concept |History of sepsis (situation)| uses this attribute to connect to the clinical finding |Sepsis|.
Finding Context : Indicates whether the clinical finding is confirmed, suspected, unknown, or absent.
For example, for the concept |No known food allergy (situation)|, the finding context is |Known absent|.
Temporal Context : Specifies when the finding occurred or is expected to occur (past, present, future).
For example, |History of sepsis (situation)| uses |In the past| as the temporal context.
Subject Relationship Context : Identifies who the clinical finding pertains to, such as the patient, a family member, or another individual.
For example, |Family history of diabetes mellitus (situation)| would indicate that the finding relates to a family member.
Examples - Associated Finding
History of monkeypox (situation)
The SNOMED CT concept 1290891000000109 |History of monkeypox (situation)| describes a past instance of monkeypox in a patient’s medical history. It is characterized by the Associated finding attribute, which specifies that the condition is 359814004 |Monkeypox (disorder)| . This indicates that monkeypox was the specific viral illness recorded in the patient’s history. The concept also includes information that the condition was confirmed as present, pertains to the patient, and occurred in the past.
Examples - Finding Context
No known food allergy (situation)
The SNOMED CT concept 429625007 |No known food allergy (situation)| indicates that the patient does not have known food allergies. A key attribute here is 408729009 |Finding context (attribute)| , which is 410516002 |Known absent (qualifier value)| . This attribute specifies that the absence of a food allergy is confirmed. Additionally, the concept includes |Associated finding (attribute)| as |Allergy to food (finding)| , showing the specific type of allergy being assessed. The |Subject relationship context (attribute)| is |Subject of record (person)| , meaning the information pertains to the patient. The |Temporal context (attribute)| is |All times past (qualifier value)| , indicating that this absence of allergy has been consistent over time.
Examples - Temporal Context
History of sepsis (situation)
The SNOMED CT concept 136611000119100 |History of sepsis (situation)| represents a patient’s past occurrence of sepsis. A key attribute here is 408731000 |Temporal context (attribute)| , which is 410513005 |In the past (qualifier value)| . This attribute specifies that the sepsis occurred in the past. The concept also includes |Associated finding (attribute)| as |Bacterial sepsis (disorder)| , indicating the specific condition recorded, and |Finding context (attribute)| as |Known present (qualifier value)| , confirming that the sepsis was known to be present. The |Subject relationship context (attribute)| is |Subject of record (person)| , indicating that the sepsis pertains to the patient themselves.
Examples - Subject Relationship Context
The SNOMED CT concept 161077003 |Father smokes (situation)| represents the smoking status of a patient’s father. Central to this concept is the Subject relationship context attribute, which is 66839005 |Father (person)| . This attribute indicates that the smoking status being recorded pertains specifically to the patient’s father. The concept also includes details such as the associated finding of |Smoker (finding)| , the finding context as |Known present (qualifier value)| , and the temporal context as |Current (qualifier value)| , reflecting that the smoking status is currently known and applies to the patient’s father.
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