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.
The SNOMED CT concept 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 . 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.
The SNOMED CT concept indicates that the patient does not have known food allergies. A key attribute here is , which is . This attribute specifies that the absence of a food allergy is confirmed. Additionally, the concept includes as , showing the specific type of allergy being assessed. The is , meaning the information pertains to the patient. The is , indicating that this absence of allergy has been consistent over time.
The SNOMED CT concept represents a patient’s past occurrence of sepsis. A key attribute here is , which is . This attribute specifies that the sepsis occurred in the past. The concept also includes as , indicating the specific condition recorded, and as , confirming that the sepsis was known to be present. The is , indicating that the sepsis pertains to the patient themselves.
The SNOMED CT concept represents the smoking status of a patient’s father. Central to this concept is the Subject relationship context attribute, which is . 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 , the finding context as , and the temporal context as , reflecting that the smoking status is currently known and applies to the patient’s father.
