Clinical Statement

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A Clinical Statement is an expression of a discrete item of clinical (or clinically related) information that is recorded because of its relevance to the care of a patient. Clinical information is fractal in nature and therefore the extent and detail conveyed in a single statement may vary. To be regarded as a clinical statement, a concept must be associated with a patient in a manner which makes clear:

  • Its temporal context
  • Its relationship to the patient
  • In the case of an observation, its mood and presence, absence or value
  • In the case of a procedure, its mood and status

This clarity may be achieved by

  • Explicit representation; or
  • Implicit application of defaults ONLY where explicitly modeled rules state the appropriate defaults.

Related

The Clinical Statement Harmonization Project is a group which has the aim to harmonize the use of Clinical Statements between the clinical domains of the HL7 v3 standard.