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Observations vs. Organizers

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3.1.1

The RIM defines the abstract ActClass "ActClassRecordOrganizer" as a navigational structure or heading used to group a set of acts sharing a common context. Record organizers include such structures as folders, documents, document sections, and batteries. The Clinical Statement model includes an Organizer class, whose class code can be valued with an ActClassRecordOrganizer subtype. Where the Organizer class is used, the value of Organizer.code MAY be drawn from the SNOMED CT [ (<<419891008 | Record artifact | ) OR (<<386053000 | Evaluation procedure | ) ] hierarchies. [[[9]]] .


It is often the case that there is a close correspondence between a particular kind of clinical statement (e.g. a blood pressure reading) and the organizer where the clinical statement is commonly found (e.g. a vital signs section). The patterns presented here are irrespective of and not dependent on the organizer in which they are found. Thus, the pattern for allergies and adverse reactions should be used regardless of any organizers they may or may not be contained in; and any distinction between a finding vs. disorder vs. diagnosis needs to be made explicit in the clinical statement itself, without reliance on the containing organizer. Stated in another way, a clinical statement needs to be a correct assertion by itself, when viewed outside the organizer. [[[10]]]