The healthcare professional who performed the action
The agent who provided the information, usually the patient or the clinician, but could be also a device or software. This attribute is optional, since it is often implicit in the information recorded.
The human subject of information, usually the patient but could also be a family member or another clinically relevant person. There are cases where subject could be more than 1, like information about the mother and child in deliveries. (by default the subject of information is the patient
The observed quality, disposition, function or process. To record several observations of the same phenomenon across time, each phenomenon is represented as a separate observation result statement (each result of certain observation process). Each of the observation process is modelled as subprocess of another observation process that spans during the whole duration of the subprocesses
The quantitative or qualitative value regarding the observed phenomenon
A subprocess of the healthcare process (e.g. A measurement process might have individual measurements at certain point in times and that span across the duration of the global measurement process)
The situation that interprets the quality / property observed. This is the inverse of the interpretsObservable property.
The process that originates the clinical statement (e.g. diagnostic procedure, history taking, etc.)
Other participants of the action (e.g. the patient, a device, etc.)
A qualifier that indicates the status of a Procedure, including prior to being initiated or completed (e.g. done, not done, contraindicated, etc.), (by default the value is done).
The body site affected or acted by a procedure
The process referred to by the statement
The clinical life phase or situation referred to by the statement. For representing more than one co-occurring situation, a clinical statement about two co-occurring clinical situations is defined as the conjunction of each of them
A qualifier that represents the condition status, i.e. if it is present, absent, suspected, at risk, unknown, etc. (by default the value is known present)
A temporal qualifier that temporally qualifies the statement as referring to the past i.e. “history”, “present” or “future” i.e. plan. (by default the temporal context refers to “present”)
Duration of the action. Relevant when the start and end point in times of the action are not known
Estimated or actual date or date time the condition was considered as resolved as reported by the clinician or the patient
Estimated or actual date or date time the condition began as reported by the clinician or the patient
A clinical situation or “Clinical life phase X” is a temporal part of an entity´s life (e.g. the patient) during which some “Clinical condition X” is present
A clinical statement about some patient clinical situation
An information entity, typically the outcome of an assessment or observation process about certain health related aspect, created by a healthcare professional
The action (typically an assessment, observation, recommendation or request) performed by a healthcare professional and whose outcome is a clinical statement which can be recorded at any point during the care process.
A clinical statement that includes information about a quality / property observed. The observed entity might represent: - Quality: A characteristic, feature, or property that is inherent in someone or something (e.g. mass of a person, age, etc.) Disposition: A characteristic or feature that is not always realized in full (e.g. antibiotic susceptibility) - Function: The ability of a person, some part of a person, or a thing to perform activities or realize processes (e.g. ability to walk) - Process: A process or outcome of a process (e.g. heart rate) The statements can be qualitative, if the absence or presence of a property is stated, or quantitative if a numerical value is attached to the observed phenomenon by counting or measuring.
Activities performed in the provision of healthcare including administration of medicines, imaging, education, therapies, administrative procedures, etc. (e.g. appendectomy, physiotherapy, etc.)