Clinical findings or observations are the active acquisition of subjective or objective information from a primary source. This includes information acquired from human observers, through recording of data via the use of scientific instruments, or indirectly from samples taken from the source, and evaluated separately.
The term observations should not be confused with Observable entity. Observable entity is the name of something that can be observed and represents a question or assessment (e.g. |systolic blood pressure|, |color of iris|, |gender|) which can produce an answer or result.
The default context for a Clinical finding concept is:
- Present (vs. being absent)
- Subject of the record (the patient)
- Current, if not specifically stated or specified to a time in the past by an entity linked to the concept
The Clinical finding hierarchy contains the subhierarchy of Disorder. Concepts that are descendants of Disease (disorder) are always and necessarily abnormal clinical states. The Disease subtype allows diseases to be subtypes of other disorders, as well as subtypes of findings.
Concepts with a semantic tag of disorder, must have a parent of Disease (disorder) or subtype of Disease (disorder).
The distinction between a disorder and a finding may be difficult to define. There are, however, distinct characteristics of each.
|Disorder vs Finding|
In some cases the disease process is irrefutable, e.g. meningococcal meningitis. In others an underlying disease process is assumed based on the temporal and causal association of the disorder and its manifestation, e.g. nystagmus (disorder) is different from nystagmus present (finding). Nystagmus present (finding) may be a normal physiological response to head rotation. A person who spins around and has nystagmus present (finding), does not have nystagmus (disorder). Alternatively, a person may have nystagmus (disorder), but not nystagmus present (finding), i.e. they do not currently manifest nystagmus. Similarly, hearing loss (disorder) is different from perception of hearing loss (finding), which can be due to a number of temporary causes, such as excessive ear wax.