标准编号：ISO/TS 22789:2010
中文名称：保健信息学 病人诊断发现和术语中问题的概念框架
英文名称：Health informatics — Conceptual framework for patient findings and problems in terminologies
发布日期：2010-06
标准范围
The purpose of this Technical Specification is to specify a categorial structure, within the subject field ofpatient findings and problems, by defining a set of common domain constraints for use within terminologicalsystems including a classification, coding scheme, coding system, reference terminology and clinicalterminology.Clinical findings are concepts that are recorded in clinical records and can describe any state observeddirectly or indirectly concerning a patient and their relationship with the environment. This TechnicalSpecification 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 processimpairing 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.
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