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Multilingual HYpertextual Thesaurus for Healthcare
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copyright for the content by CEN members and Project Team PT27 "Domain Termlist" of CEN/TC251, 1999


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(extract from " Annex D (Normative) Archetypes and Fine-Grained Descriptors" of the document CEN/TC251/PT27 N37, version 0.41 of 1999-04-15)

D.2 List of fine-grained descriptors

Table D.2 below provides a set of fine-grained descriptors, organized by semantic category.

 

Table D.2: List of descriptors.

(semantic categories and subcategories are marked with *)

 

 

clinical situation

* physiopathological condition or state

** normal condition

** abnormal condition
     - illness
     - disease
     - symptom
     - sign
     - lesion
     - injury
     - coma
     - death
     - diabetic
     - cardiopathic
     - dialyzed
     - hypersensitivity
     - infection
     - wound
     - deformity
     - allergy state
     - healthy carrier of disease
     - carrier of prosthesis

** property

*** constitutional features
     - age group
     - sex
     - appearance
     - aspect

**** vital sign
     - body height
     - body weight
     - blood pressure
     - body temperature

** body process
     - birth
     - development
     - childhood
     - pregnancy
     - delivery
     - grooming
     - growth
     - nutrition
     - respiration

** family dynamics and relationships

* event

** healthcare event
     - episode of care
     - contact
     - encounter
     - stay
     - visit
     - episode of illness
     - episode within problem
     - exposition to risk

** non-healthcare event
     - family event
     - occupational event
     - travel

*** accident
     - ingestion
     - contact
     - traumatic event

* lifestyle feature

** activity of daily life
     - personal hygiene
     - movement
     - autonomy

** habit
     - dietary habit
     - alcohol habit
     - tobacco habit
     - non-therapeutical drugs habit

** education

** occupation

** marital status

** residence status

* healthcare activity

** acquiring information
     - history taking
     - review of systems
     - physical examination

*** investigation
     - appraising
     - examining
     - measuring
     - monitoring
     - observing

*** recording of images and signals
     - signal acquisition
     - image acquisition

** decision-making activity
     - application of decision criteria from a guideline
     - impression
     - judgement
     - opinion

*** interpretation
     - signal interpretation
     - image interpretation
     - interpretation of findings

** therapeutic activity
     - psychotherapy
     - nursing intervention

*** physical actions
     - surgical operations
     - physiotherapy
     - wound dressing

*** drug-related hc activity
     - drug prescription
     - drug administration
     - assuming medication

*** preventive activity
     - immunization activity
     - screening
     - cancer screening

*** information and education activity
     - advicing
     - counseling
     - educating
     - supporting
     - training

** administrative activity (and workflow management)
     - coordination
     - admitting
     - discharging
     - transferring
     - interact (with other professionals)
     - contacting (patient or relatives)
     - booking (an appointment)
     - certifying
     - notifying
     - controlling
     - ordering
     - requesting
     - writing (a prescription)
     - referring
     - reporting
     - preparing a plan
     - performing (an activity)

 

associate topic
     - abnormal structure
     - image
     - signal
     - method
     - measure-independent circumstance

* substance
     - air
     - food
     - environmental substance
     - contrast agent
     - radiopharmaceutical agent

* healthcare agent

** healthcare party
     - person
     - healthcare organization

** product

*** device
     - imaging device
     - instrument
     - prosthesis

*** medicinal product
     - vaccine

*** healthcare software

* environment

** location
     - ward
     - room
     - bed
     - patientís residence
     - school
     - working place
     - prison

*** healthcare location
     - hospital
     - outpatient clinic
     - emergency department
     - diagnostic department
     - day hospital service
     - nursing home
     - GP clinic
     - laboratory service provider

* body component

** body in general
     - physical

** circulatory system
     - heart
     - blood vessel
     - artery
     - vein

** digestive system
     - mouth
     - tooth
     - stomach
     - intestine

** eye

** ear

** musculoskeletal system
     - muscle
     - skeleton

** neurological system

** mental-psychological
     - emotional
     - cognition

** respiratory system
     - nose
     - throat
     - lung

** skin

** metabolic system
     - endocrine system

** urinary system

** male genital system

** female genital system

** body region
     - head
     - face
     - neck
     - chest
     - breast
     - abdomen
     - extremity

** abnormal structure

** body substance

 

qualifiers

* abnormality qualifier
     - normal
     - deviant
     - abnormal
     - pathologic

* existence qualifier
     - present
     - absent

* successfulness
     - successful
     - unsuccessful

* spatial qualifiers

** relative position
     - right zone
     - left zone
     - upper zone
     - lower zone

** laterality selector
     - right one
     - left one

** position of patient

*** position wrt gravity
     - standing
     - sitting
     - lying

*** position wrt device
     - inserted
     - in contact with skin
     - external

* time-related qualifiers

** life cycle
     - needed
     - under consideration
     - to be done
     - planned
     - ordered
     - scheduled
     - initiated
     - in process
     - suspended
     - postponed
     - not done

*** occurrence status
     - completed
     - normally concluded
     - exceptionally not done
     - rejected
     - cancelled
     - cancelled by patient
     - cancelled by requestor
     - aborted
     - interrupted

** potentiality
     - actual
     - goal
     - predicted
     - expected
     - at risk

** process status
     - active
     - inactive
     - current
     - resolved
     - dormant
     - new
     - ongoing
     - recent
     - past
     - former
     - temporary

** obsolescence
     - the current one
     - the previous one

** urgency
     - emergency
     - routinely

** timing marker
     - before event
     - at event
     - during event
     - after event
     - at admission
     - during contact
     - at discharge
     - after discharge
     - initial
     - presenting
     - at beginning

* information-related qualifiers

** certainty
     - reasonable evidence
     - uncertain

** negation
     - affirmative
     - negated

** knowing mode
     - subjective
     - objective
     - estimated
     - observed
     - calculated
     - assessed
     - reported
     - estimated by author
     - observed by author
     - calculated by author
     - assessed by author
     - reported by other professional
     - reported by patient
     - reported by patientís representative
     - reported by another party

** relevance
     - primary
     - secondary

* communication modality
     - stand alone

** one way
     - paper
     - electronic message
     - previous record

** two ways interaction
     - face to face
     - telephon
     - electronic meeting
     - telepresence

 

roles

* role for clinical situations
     - problem
     - problem component (sub-problem)
     - need
     - trigger event
     - reason for contact
     - alert
     - result

* role for conditions (roles for clinical situations, plus: )
     - compaint
     - diagnosis
     - finding
     - contraindication
     - side effect
     - complication
     - adverse reaction
     - prognosis
     - outcome

* role for activities (roles for clinical situations, plus: )
     
- preparatory activity
     - preliminary examination
     - challenge
     - follow-up

* role for secondary categories
     - sample
     - region of interest
     - approach
     - route
     - component
     - system

** actor
     - representative of patient
     - carer

*** healthcare professional
     - physician
     - general practitioner
     - specialist
     - dentist
     - nurse
     - therapist
     - physiotherapist
     - dietician
     - radiographer
     - laboratory scientist
     - social worker
     - pharmacist
     - secretary
     - transcriptionist
     - medical record keeper

*** patient
     - inpatient
     - outpatient

*** patient related party
     - family in general
     - next of kin
     - relative
     - parent
     - father
     - mother
     - grand-parent
     - other ancestor
     - child
     - other descendant
     - sibling
     - other consanguineous relative
     - partner
     - other relative-in-law
     - friend
     - employer
     - tutor
     - guardian
     - prison officer
     - person in contact at home
     - person in contact at school
     - person in contact at work
     - person in contact during travel
     - neighbour
     - other person in contact

** role in healthcare process
     - carried out procedure
     - assisted with the procedure
     - provided a service
     - responsible for a period of care
     - coordinator of shared care
     - authorised a report
     - source of a request or referral
     - destination of a request or referral
     - originator of the information (i.e. if information from another source is entered from a paper form).
     
- recorded the information
     - reported the recorded information

** healthcare agent relationship
     - employer of
     - responsible for
     - employee of
     - responsible to
     - sub-division of
     - parent organisation of

** position of healthcare professional
     - head of department
     - hospital consultant
     - trainee

** subject of information (any patient, patient related party, plus: )
     
- blood product unit
     - donor
     - control
     - community
     - fetus (for a mother/pregnant woman)
     - mother/pregnant woman (for a fetus)
     - animal or machine causing injury
     - prosthesis
     - instrument or device in contact with the patient

* role for dates (precoordinated descriptors are provided here as shortcuts for particular uses)

** dates of documenting
     - date of document creation
     - date of transaction in database
     - date of dictation
     - date of transcribed
     - date of sign-off
     - date of attestation
     - date of recording
     - stated record date
(If information is being entered from a paper record or another source this may differ from the system generated time stamp for the recording date and time.)

** dates of awareness
     - date of reporting by patient
     - date of reading of message
     - date of observing by professional
     - date of results became available
     - date of diagnosis

** dates of clinical events
     - date of event

*** dates of particular events
     - date of birth
     - date of death
     - date of consultation
     - date of projection
     - date of procedure
     - date of challenge
     - date of sampling
     - date of lab processing
     - date of verification
     - date of QA review

*** dates within clinical events
     - date of onset
     - date of recovery
     - date procedure began or was commenced on
     - date procedure ended or completed on
     - date procedure is scheduled to start on
     - date procedure is scheduled to end on
     - schedule is planned on

 


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