Problem-oriented Medical Record Ontology

GALEN Definition

          (Process whichG playsClinicalRole SurgicalRole) name SurgicalDeed.

      

GALEN Definition

          (Process whichG playsClinicalRole SurgicalRole) name SurgicalDeed.

      

WIkipedia Definition

The medical history or anamnesis[1] of a patient is information gained by a physician or other healthcare professional by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. This kind of information is called the symptoms, in contrast with clinical signs, which are ascertained by direct examination.

Rather than explicitely referring (within the patient record) to instances of a class called 'history' (which act as input to activities in the care process), information-objects realized by instances of this class are assumed to be considered a case history (relative - temporaly - to the screening acts)

WIkipedia Definition

The medical history or anamnesis[1] of a patient is information gained by a physician or other healthcare professional by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. This kind of information is called the symptoms, in contrast with clinical signs, which are ascertained by direct examination.

Rather than explicitely referring (within the patient record) to instances of a class called 'history' (which act as input to activities in the care process), information-objects realized by instances of this class are assumed to be considered a case history (relative - temporaly - to the screening acts)

Wordnet Definition

See: symptom

Wikipedia Definition

See: Symptom:

Strict ly, a symptom is a sensation or change in health function experienced by a patient. Thus, symptoms may be loosely classified as strong, mild or weak. In this, medically correct, sense of the word, it is a subjective report, as opposed to a sign, which is objective evidence of the presence of a disease or disorder. Examples of symptoms are fatigue/tiredness, pain, or nausea. In contrast, elevated blood pressure, or abnormal appearance of the retina, would be a medical sign indicating the nature of the disease.

GALEN (GRAIL) Definition(s)

        (Phenomenon whichG playsConsultationRole SymptomRole) name Symptom.

      

interpetant-of can be thought of as somewhat related to how isConsultationRolePlayedBy relates a SymptomRole with the phenomenon which 'plays' it

Wordnet Definition

See: symptom

Wikipedia Definition

See: Symptom:

Strict ly, a symptom is a sensation or change in health function experienced by a patient. Thus, symptoms may be loosely classified as strong, mild or weak. In this, medically correct, sense of the word, it is a subjective report, as opposed to a sign, which is objective evidence of the presence of a disease or disorder. Examples of symptoms are fatigue/tiredness, pain, or nausea. In contrast, elevated blood pressure, or abnormal appearance of the retina, would be a medical sign indicating the nature of the disease.

GALEN (GRAIL) Definition(s)

        (Phenomenon whichG playsConsultationRole SymptomRole) name Symptom.

      

interpetant-of can be thought of as somewhat related to how isConsultationRolePlayedBy relates a SymptomRole with the phenomenon which 'plays' it

Wordnet Defnitions

Assay:

A quantitative or qualitative test of a substance (especially an ore or a drug) to determine its components; frequently used to test for the presence or concentration of infectious agents or antibodies etc.)

Diagnostic test:

An assay conducted for diagnostic purposes.

Wordnet Defnitions

Assay:

A quantitative or qualitative test of a substance (especially an ore or a drug) to determine its components; frequently used to test for the presence or concentration of infectious agents or antibodies etc.)

Diagnostic test:

An assay conducted for diagnostic purposes.

Laboratory for Applied Ontology (LOA)

A substance used in the treatment, diagnosis, prevention, or analysis of normal and abnormal body function. This includes substances that occur naturally in the body and are administered therapeutically.

Laboratory for Applied Ontology (LOA)

A substance used in the treatment, diagnosis, prevention, or analysis of normal and abnormal body function. This includes substances that occur naturally in the body and are administered therapeutically.

Reconciling HL7 RIM Inconsistencies

The cpr:clinical-description class is an attempt to reconcile the ontological inconsistencies with the archetype of a recording of an act and the thing the recording describes (which could be either a continuant / endurant or an occurrant / perdurant).

about

The relation between information objects and entities they are about. The difference with 'expresses' is that the last requires a situation to be about something. E.g. Dante's Comedy is about facts like Dante's travel to the hereafter. The Comedy expresses a script as well as various related meanings, while the facts talked about are not 'expressed'. Given that descriptions are expressed by at least one IO, and that interpretations of IOs requires conceiving a description, and the (plausible) claim that being about something can only be done in context, i.e. within a situation, we can propose that the conceived description is satisfied by the situation (the context) of the entity the IO is about.On this basis, about would result to be a mediated relation. This is still a proposal, then we keep about here as a primitive for some time.

depiction

An information realization consisting of depicted images/signs of any sort (e.g. graffiti, drawings, inscriptions, pictures, sculptures, etc.), which are inscripted on a medium that lasts longer than the depicting act. It also includes any early form of inscripted iconic expression, which can be considered as original bodily expressions.

REPRESENTATIONAL ARTIFACT

A representation that is fixed in some medium in such a way that it can serve to make the cognitive representations existing in the minds of separate subjects publicly accessible in some enduring fashion. Examples are: a text, a diagram, a map legend, a list, a clinical record, or a controlled vocabulary.

Act (HL7 RIM)

A record of something that is being done, has been done, can be done, or is intended or requested to be done.

One of the goals of this ontology is to facilitate the use of owl-time constructs to express temporal qualities using foundational ontology terms such as:

• has-quality

As such time:TemporalEntity serves as a syntactic proxy for temporal-quality

Reconciling HL7 RIM Inconsistencies

The cpr:clinical-description class is an attempt to reconcile the ontological inconsistencies with the archetype of a recording of an act and the thing the recording describes (which could be either a continuant / endurant or an occurrant / perdurant).

about

The relation between information objects and entities they are about. The difference with 'expresses' is that the last requires a situation to be about something. E.g. Dante's Comedy is about facts like Dante's travel to the hereafter. The Comedy expresses a script as well as various related meanings, while the facts talked about are not 'expressed'. Given that descriptions are expressed by at least one IO, and that interpretations of IOs requires conceiving a description, and the (plausible) claim that being about something can only be done in context, i.e. within a situation, we can propose that the conceived description is satisfied by the situation (the context) of the entity the IO is about.On this basis, about would result to be a mediated relation. This is still a proposal, then we keep about here as a primitive for some time.

depiction

An information realization consisting of depicted images/signs of any sort (e.g. graffiti, drawings, inscriptions, pictures, sculptures, etc.), which are inscripted on a medium that lasts longer than the depicting act. It also includes any early form of inscripted iconic expression, which can be considered as original bodily expressions.

REPRESENTATIONAL ARTIFACT

A representation that is fixed in some medium in such a way that it can serve to make the cognitive representations existing in the minds of separate subjects publicly accessible in some enduring fashion. Examples are: a text, a diagram, a map legend, a list, a clinical record, or a controlled vocabulary.

Act (HL7 RIM)

A record of something that is being done, has been done, can be done, or is intended or requested to be done.

One of the goals of this ontology is to facilitate the use of owl-time constructs to express temporal qualities using foundational ontology terms such as:

• has-quality

As such time:TemporalEntity serves as a syntactic proxy for temporal-quality

Diagnosis Role

Both GALEN and OBI define diagnosis roles:

GALEN Diagnosis

        (Phenomenon whichG playsConsultationRole DiagnosisRole) name Diagnosis.

      

OBI Diagnosis Role (OBI_159)

A diagnostic role is a role which is assigned to an entity when it is used to identify the nature or cause of some phenomenon (i.e. a diagnosis). - http://wordnet.princeton.edu/perl/webwn?s=diagnosis

Diagnosis Role

Both GALEN and OBI define diagnosis roles:

GALEN Diagnosis

        (Phenomenon whichG playsConsultationRole DiagnosisRole) name Diagnosis.

      

OBI Diagnosis Role (OBI_159)

A diagnostic role is a role which is assigned to an entity when it is used to identify the nature or cause of some phenomenon (i.e. a diagnosis). - http://wordnet.princeton.edu/perl/webwn?s=diagnosis

Wordnet Definition

..care provided to improve a situation (especially medical procedures or applications that are intended to relieve illness or injury)

GALEN Defintion

        ClinicalAct newSub TreatmentAct.

      

NHS Clinical Headings

Any activity which is undertaken to maintain or improve a patient/client's state of health and well-being, relieve distress or reduce risk

HL7 RIM Definition

An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject.

Laboratory for Applied Ontology (LOA)

A procedure, method, or technique designed to prevent a disease or a disorder, or to improve physical function, or used in the process of treating a disease or injury.

Wordnet Definition

..care provided to improve a situation (especially medical procedures or applications that are intended to relieve illness or injury)

GALEN Defintion

        ClinicalAct newSub TreatmentAct.

      

NHS Clinical Headings

Any activity which is undertaken to maintain or improve a patient/client's state of health and well-being, relieve distress or reduce risk

HL7 RIM Definition

An Act whose immediate and primary outcome (post-condition) is the alteration of the physical condition of the subject.

Laboratory for Applied Ontology (LOA)

A procedure, method, or technique designed to prevent a disease or a disorder, or to improve physical function, or used in the process of treating a disease or injury.

Alignment with OBI

TODO Align with OBI_155 once it settles

Ontology of Biomedical Reality

Relying on the FMAs definition of anatomical structure, we distinguish anatomical (normal) from pathological (abnormal) material entities; the latter resulting from processes other than those governed by the organism’s structural genes. We also extend the FMAs representation of material entities

Alignment with OBI

TODO Align with OBI_155 once it settles

Ontology of Biomedical Reality

Relying on the FMAs definition of anatomical structure, we distinguish anatomical (normal) from pathological (abnormal) material entities; the latter resulting from processes other than those governed by the organism’s structural genes. We also extend the FMAs representation of material entities

POMR Definition

Consists mainly of problems that clearly require the intervention of a health care professional. These include acute problems requiring hospitalization and chronic problems requiring long-term management. Such problems usually offer at least some risk of impairment or disability especially if diagnosis or management is not handled properly.

Relation to GALEN's "Basic Template for Signs and Symptoms"

This 'defined class' can be considered equivalent to GALEN's SignSymptomOrDiagnosis.

POMR Definition

Consists mainly of problems that clearly require the intervention of a health care professional. These include acute problems requiring hospitalization and chronic problems requiring long-term management. Such problems usually offer at least some risk of impairment or disability especially if diagnosis or management is not handled properly.

Relation to GALEN's "Basic Template for Signs and Symptoms"

This 'defined class' can be considered equivalent to GALEN's SignSymptomOrDiagnosis.

GALEN Definition

        (MechanicalPropulsion whichG <
      actsSpecificallyOn Drug
      hasUniqueAssociatedDisplacement (Displacement which isDisplacementTo BodyStructure)>
) name DrugAdministration.

      

HL7 RIM Defnition (SubstanceAdministration-cls)

The act of introducing or otherwise applying a substance to the subject.

Discussion: The effect of the substance is typically established on a biochemical basis, however, that is not a requirement. For example, radiotherapy can largely be described in the same way, especially if it is a systemic therapy such as radio-iodine. This class also includes the application of chemical treatments to an area.

GALEN Definition

        (MechanicalPropulsion whichG <
      actsSpecificallyOn Drug
      hasUniqueAssociatedDisplacement (Displacement which isDisplacementTo BodyStructure)>
) name DrugAdministration.

      

HL7 RIM Defnition (SubstanceAdministration-cls)

The act of introducing or otherwise applying a substance to the subject.

Discussion: The effect of the substance is typically established on a biochemical basis, however, that is not a requirement. For example, radiotherapy can largely be described in the same way, especially if it is a systemic therapy such as radio-iodine. This class also includes the application of chemical treatments to an area.

GALEN Definition

          NAMEDVolitionalAct newSub ClinicalAct.

      

Knowledge Representation for Relevance Ranking of Patient-Record Contents in Primary-Care Situations

Elisabeth Bayegan follows the clinical headings set as a framework for a class of 'clinical acts':

The NHS Clinical Headings Project’s main objective has been to identify a limited number of headings that will perform the jobs that are needed for clinical communicationand navigation and that can be agreed upon by every participant involved in clinical communication. The project produced a well-established framework of clinical headings compatible with HL7 and CEN TC251’s standardization work on electronic patient records. Clinical Headings refer to a set of words and phrases that clinicians use to name sections of their communications (e.g., symptoms, examination findings,