Open healthCare Ontology (OpenCare) is an integrated metadata vocabulary expressed as an ontological data model, to facilitate the effective reasoning of patient-specific electronic health record (EHR) data. The OpenCare model identifies the concepts and semantic types in the EHR data with the aim of enabling the representation of clinical data in a way that is accessible and usable by researchers and healthcare facility users. The development of OpenCare and its components is formalized using the Ontology Web Language (OWL). This framework aims to enhance the accessibility and user-friendliness of EHR clinical data. OCO: Open healthCare Ontology Opencare 2023-05-24 Bain, Debanjali Dutta, Biswanath https://creativecommons.org/licenses/by/4.0/ OCO https://w3id.org/opencare https://w3id.org/opencare CQ 1: What is the patient's medical history for a specific condition? CQ 2: What medications has the patient been prescribed, and for what duration? CQ 3: What are the vital signs and measurements of the patient over a certain period? CQ 4: What is the patient's current diagnosis, and what tests were performed to determine it? CQ 5: Retrieve all patients who have been diagnosed with certain diseases (e.g., COVID-19, diabetes mellitus, etc.) and are over the age of 40. CQ 6: Retrieve the surgery name and date of all patients who underwent a surgical procedure within the past 6 months. CQ 7: What are the allergies and adverse reactions of the patient to specific drugs? CQ 8: What is the patient's family medical history, and how does it affect their current condition? CQ 9: What are the current and past treatments that the patient has received for a specific condition? CQ 10: What is the patient's current clinical status, and what are the prognoses for their condition? Description may include but is not limited to: an abstract, table of contents, reference to a graphical representation of content or a free-text account of the content. Description This object property indicates that a patient has been admitted to a medical facility, such as a hospital or clinic, for treatment. admitted The phrase "admitted in" usually refers to a patient being admitted to a hospital or other healthcare facility for treatment. It indicates that the patient has been officially registered and accepted as a patient by the facility, and is being provided with medical care and support. admitted in SCTID 473011001 The disposition to develop an allergic reaction, the allergic reaction itself or its consequences. (SNOMEDCT_US) Solismed has allergic condition Allergy :conditions SNOMED CT Relates a medical condition or symptom that is caused by an allergy to an allergen. is allergic condition of The term "has allergy status" could refer to a patient's current status regarding their allergies. It could mean whether the patient currently has any allergies or not, as well as the severity and nature of their allergies. The status may be documented in the patient's medical record or communicated to healthcare providers during a patient encounter. For example, a patient's allergy status may be noted as "no known allergies" or "allergic to penicillin with a moderate reaction." This information can be important for healthcare providers to know when prescribing medications or planning treatments for the patient. has allergy status Relates the current status of a patient's allergy to an allergen. is allergy status of causes This object property indicates the primary medical complaint or symptom reported by a patient to a healthcare provider. chief complaint Relates the primary medical condition, symptom, or concern reported by a patient to their healthcare provider. chief complaint of consists The phrase "contained in" is typically used to refer to the presence or existence of something within a particular object or substance. For example: The active ingredient in this medication is contained in a small capsule. The toxin was found to be contained in the water supply. The important data is contained in this file on my computer. In a medical context, this phrase might be used to refer to a particular substance or component within the body. For instance, a physician might say, "The virus is contained in the patient's blood," or "The cancer cells are contained in the lymph nodes." contained in located in contains This object property indicates that a medical device or implant is contained within the body of a patient. The domain is the body and the range is the medical device or implant. contains implant The phrase "diagnosed with" typically indicates that a medical condition has been identified or diagnosed in a patient. It is often used in medical reports and records to document a patient's medical history and current health status. For example: "The patient was diagnosed with diabetes mellitus type 2 and prescribed metformin." Source: American Medical Association. (2019). Current Procedural Terminology (CPT) Professional Edition. diagnosed with This object property indicates that a patient has been discharged from a medical facility, such as a hospital or clinic, after treatment. discharged This object property indicates that a patient has had an encounter with a healthcare provider, such as a doctor or nurse, for the purpose of receiving medical care. encountered The phrase "encountered by" typically refers to a patient who has been seen or treated by a healthcare provider, such as a physician or nurse. It can also be used to describe a medical condition or symptom that a patient has experienced. For example, "The patient was encountered by the nurse in the emergency department and complained of chest pain." encountered by This object property indicates the gender of an individual. The domain is the individual and the range is a gender class, such as male or female. gender of A substance that causes an allergic response. Examples include pollen, molds, and certain foods. (NCI) A substance that elicits an allergic reaction. (NCI) Antigen-type substances that produce immediate hypersensitivity (HYPERSENSITIVITY, IMMEDIATE). (MSH) Products containing allergenic substances used for allergy diagnosis or treatment. (SNOMEDCT_US) has allergen name has allergy source a person who has a predisposition to allergies has been prescribed or is taking medication to treat their allergy symptoms. has allergy medication "Has allergy severity" refers to the assessment or measurement of the severity of an allergic reaction. This information can be important in determining the appropriate treatment and management for the patient's allergy. For example, a patient with a mild allergy may only require avoidance of the allergen or use of over-the-counter antihistamines, while a patient with a severe allergy may require prescription medications such as epinephrine or corticosteroids and may need to carry an epinephrine auto-injector with them at all times. The severity of an allergy can be determined through clinical evaluation, allergy testing, or previous history of allergic reactions. has allergy severity The phrase "has body temperature" typically refers to the measurement of a person's body temperature using a thermometer. This measurement is an important vital sign that can help diagnose certain illnesses and track the progress of a patient's condition. A normal body temperature for adults ranges between 97°F to 99°F (36.1°C to 37.2°C), but it may vary depending on factors such as age, time of day, and physical activity. Abnormal body temperatures can be a sign of a fever or hypothermia, among other conditions. has body temperature has child has city "Has clinical finding" refers to a medical term used to describe the signs or symptoms that a patient is experiencing or any abnormality or disease that has been detected during the physical examination or diagnostic tests. It can be used to describe any abnormality found in the patient's physical or mental health. For example, a clinical finding can be the presence of a lump during a breast examination, an irregular heartbeat detected during a cardiac evaluation, or a rash seen during a skin examination. These clinical findings are important in establishing a diagnosis and determining appropriate treatment for the patient. has clinical finding has country has daughter has diagnosis type This object property indicates that a patient has undergone a diagnostic procedure, such as a blood test or MRI, for the purpose of identifying a medical condition or disease. has diagnostic procedure "The destination of a patient after medical treatment, especially after emergency triage, first line treatment, or surgery; the choice made for the next venue of care. The patient was given a disposition for outpatient care, as ward admission was not indicated. https://en.wiktionary.org/wiki/disposition# " has disposition has district The term "has encounter history" generally refers to the past medical history of a patient, specifically with regard to their previous medical encounters or visits. This information includes a record of previous diagnoses, treatments, hospitalizations, surgeries, and other medical interventions that the patient has undergone. The encounter history is an important aspect of a patient's medical record as it helps healthcare providers understand the patient's medical background and provide appropriate care. It can also aid in the diagnosis of current health conditions and in the development of treatment plans. has encounter history The attribute "has encounter type" refers to the type of medical encounter or visit that a patient has with a healthcare provider. It is a property that can be associated with a patient or a medical encounter. Examples of encounter types include routine check-ups, emergency visits, follow-up appointments, hospital admissions, and specialist consultations. This information is important for healthcare providers to document and track to ensure that patients are receiving appropriate care and treatment. has encounter type This object property indicates the gender of an individual. The domain is the individual and the range is a gender class, such as male or female. has gender This object property indicates the result of a genetic test performed on a patient, such as a test for inherited diseases or genetic predispositions. has genetic test result The term "has health record" can refer to a variety of things, depending on the context. In general, it means that the person has some kind of record or documentation of their medical history or health status. This could include things like: Electronic health records (EHRs) maintained by healthcare providers Personal health records (PHRs) maintained by the individual or a third-party service Paper records kept by healthcare providers or the individual Insurance claims and billing records that document past medical services received Prescription records maintained by pharmacies or the individual Having a health record can be important for managing one's own health, as well as for sharing information with healthcare providers when seeking medical care. Health records may contain information about a person's past medical conditions, surgeries, allergies, medications, immunizations, and more. has health record This object property indicates the result of an imaging procedure performed on a patient, such as an X-ray or CT scan. has image result The attribute 'has implant procedure' describes a medical procedure in which an implant is placed in a patient's body. This attribute is used to document the details of the procedure, including the type of implant used, the location of the implant, and any relevant information about the surgery. For example, a patient may have a hip replacement surgery in which a prosthetic hip implant is placed in their body. In this case, the 'has implant procedure' attribute would be used to record the details of the surgery, such as the type of implant used, the location of the implant, and any relevant information about the procedure, such as the surgeon who performed the surgery and the date of the surgery. has implant procedure This object property indicates the result of a laboratory test performed on a patient, such as a blood test or urinalysis. has lab test result This object property indicates the location of an entity, such as a medical facility or a patient's residence. has location The phrase "has no symptom" refers to the absence of any particular symptom or set of symptoms in an individual. It indicates that the person is not experiencing any physical or psychological signs of illness or injury. This information may be recorded in a medical record or reported by the individual during a medical encounter. It can be an important piece of information for healthcare providers in ruling out certain conditions or assessing the overall health of the individual. has no symptom The phrase "has observational finding" typically refers to the result of a medical examination or test that has been performed on a patient. It indicates that a clinician or medical professional has observed something specific during the examination or test that is relevant to the patient's condition or health status. Examples of observational findings could include the presence of a particular symptom, the results of a blood test, or the appearance of an abnormality on an X-ray or other imaging test. The observational finding is typically documented in the patient's medical record or health chart and may be used to guide further diagnostic or treatment decisions. has observational finding has parent This object property indicates the past medical history of a patient, including previous diagnoses, treatments, and procedures. has past history 'has place of encounter' refers to the location where a patient encounter takes place. It can be a hospital, clinic, doctor's office, or any other healthcare facility. This information is important for medical professionals to keep track of because it helps them identify patterns in patient encounters and outcomes. For example, if a high number of patients are experiencing adverse events at a particular hospital, it could indicate a problem with the quality of care or facilities at that location. The place of encounter can also affect the type of care that a patient receives, as different facilities may have different levels of resources and expertise. Therefore, it is important to document the place of encounter accurately in a patient's medical record. has place of encounter has place of visit This object property indicates the healthcare provider who prescribed a medication or treatment to a patient. has prescribed by Relates a medical condition, disease, or symptom that the patient is currently experiencing or has experienced in the recent past with a patient or a medical record. has present history The phrase "has referred to hospital" typically indicates that the patient has been recommended to go to the hospital for further evaluation or treatment by a medical professional. This may occur if the patient's condition cannot be managed adequately in an outpatient setting, or if the medical professional believes that more specialized care is necessary. In a medical record, this information might be documented in the patient's history or progress notes. For example: "Patient referred to hospital for further evaluation of chest pain." The documentation might also include the name of the healthcare professional who made the referral and the reason for the referral. has referred to hospital Designation of the part of the body through which or into which, or the way in which, the medicinal product is intended to be introduced. In some cases a medicinal product can be intended for more than one route and/or method of administration. (NCI) In medical terms, route refers to the way in which a drug is administered to a patient. This can include various methods such as oral, intravenous, topical, subcutaneous, and more. For example, a medication may be administered orally (by mouth), topically (applied to the skin), or intravenously (through a vein). The route of administration can affect how quickly the medication takes effect, how long it remains in the body, and the potential for side effects. So, the statement 'drug has route' means that the medication in question is associated with a particular method or route of administration. The various ways of administering a drug or other chemical to a site in a patient or animal from where the chemical is absorbed into the blood and delivered to the target tissue. (MSH) has route has son Relates a healthcare professional with their area of medical specialization or expertise. has specialization has surgical history The attribute 'has symptom' is used to indicate that a person or a patient has reported or is showing a particular symptom. It is typically used in medical contexts to describe a sign or indication of a disease or illness. For example, a patient may have a fever, cough, or headache, which are all symptoms of various illnesses. By documenting the symptoms a patient is experiencing, healthcare providers can make a more accurate diagnosis and develop a treatment plan. has symptom bodysite from where temperature has taken. has temperature source "Has treatment plan medication" refers to the prescription or administration of medication as part of a patient's treatment plan. This means that a healthcare provider has recommended a specific medication or combination of medications to manage or treat a patient's medical condition. The medication may be intended to alleviate symptoms, cure or manage the underlying condition, prevent the condition from worsening, or achieve other therapeutic goals. The treatment plan may include various components, such as lifestyle modifications, therapy, and follow-up appointments, in addition to medication. The specific medication prescribed or recommended will depend on the patient's medical history, symptoms, and other individual factors, as well as the healthcare provider's clinical judgment and expertise. Example: If a patient is diagnosed with high blood pressure, their healthcare provider may create a treatment plan that includes medication to help lower their blood pressure. The medication prescribed may be an ACE inhibitor, a diuretic, a calcium channel blocker, or a combination of these medications, depending on the patient's individual health profile and other factors. The healthcare provider will also recommend lifestyle modifications, such as a healthy diet and regular exercise, as part of the treatment plan to help manage the patient's high blood pressure. The patient will then take the prescribed medication as directed, and attend follow-up appointments to monitor their progress and adjust the treatment plan as needed. EHRMDS has treatment plan medication The property 'has treatment plan referral' describes a medical act of referring a patient to another healthcare provider or facility for further diagnosis, treatment, or management of a medical condition. It refers to a plan of action developed by a healthcare provider for a patient that may include recommendations for consultations with specialists, imaging studies, laboratory tests, or additional medical interventions. For example, if a patient is experiencing severe back pain, their primary care physician may develop a treatment plan that includes a referral to a physical therapist or orthopedic specialist for further evaluation and treatment. The property 'has treatment plan referral' would capture this information as part of the patient's medical record. EHRMDS has treatment plan referral "Has treatment procedure" refers to the medical procedure or intervention that has been prescribed or recommended for a patient's medical condition. It includes any surgical, therapeutic, or diagnostic procedure that a healthcare professional has planned to perform on the patient as part of their treatment plan. The details of the treatment procedure are usually documented in the patient's medical record, including the name of the procedure, the date it was performed, and any other relevant information such as the location, anesthesia used, and the outcome of the procedure. has treatment procedure has unit "Implant occurred in" can refer to the placement of a medical device or implant into a patient's body. This information is typically documented in the patient's medical record and may include details such as the date of the implant procedure, the type of implant, and the location in the body where the implant was placed. This information is important for ongoing medical care and follow-up as it may impact future treatment plans and management of any potential complications. implant occurred in Relates an allergen with a patient who is allergic to it. is allergen for is source of allergy for Relates a measure of the severity of an allergic reaction to an allergen with a patient. is allergy severity of Relates the body temperature measurement with a patient or a medical record. is body temperature of 'is caused by' refers to the underlying factors or conditions that lead to the development of a particular disease or condition. This can include genetic predisposition, environmental factors, lifestyle choices, and various other factors. Understanding the cause of a disease or condition is crucial for effective treatment and management, as it can guide the selection of appropriate interventions and therapies. For example, a patient with a history of smoking and exposure to environmental toxins may be at a higher risk for developing lung cancer, which can help guide screening and prevention efforts. The phrase "is caused by" is often used to indicate the reason behind a certain event or condition. It implies that something is responsible for bringing about a specific outcome. For example, smoking is caused by the inhalation of tobacco smoke, and obesity is caused by a combination of genetic and environmental factors, such as poor diet and lack of exercise. It is important to identify the cause of a problem in order to determine the most effective treatment or prevention strategy. is caused by isCityOf Relates a clinical observation, examination, or test result with a medical condition or disease in a patient or a medical record. is clinical finding of isCountryOf is daughter of Relates a medical diagnosis with a patient or a medical record. is diagnosis of is diagnosis type of Relates a diagnostic procedure with a medical condition or disease in a patient or a medical record. is diagnostic procedure of isDistrictOf Indicates that an encounter history is related to an individual. is encounter history of Indicates that an encounter type is related to an encounter. is encounter type of Indicates that a genetic test result is related to an individual. is genetic test result of Indicates that a health record is related to an individual. is health record of Indicates that an image result is related to an individual or a body part or imaging procedure is image result of Indicates that an implant procedure is related to an individual. is implant procedure of Indicates that a lab test result is related to .'Laboratory finding is lab test result of is location of Indicates that a symptom is not related to a condition or encounter. is not symptom for Indicates that an observational finding is related to an individual or a body part or encounter. is observational finding of Indicates that a place of encounter is related to an encounter. is place of encounter of Indicates that a referral hospital is related to an individual or a healthcare provider. is referral hospital of Indicates that a route is related to a medical intervention or procedure. is route of Indicates the system of the body that was reviewed during a clinical examination or review of systems. is site of system review for is son of Indicates the area of medical specialization of a healthcare professional. is specialization of Indicates the symptom experienced by a patient. is symptom of Indicates the source of the temperature measurement of a patient. is temperature source of Indicates the medication prescribed as part of a treatment plan. is treatment plan medication of Indicates the healthcare professional or facility to which a patient is referred as part of a treatment plan. is treatment plan referral of Indicates the medical procedure that is part of a treatment plan. is treatment procedure of is unit of Indicates the medication or treatment used to treat a specific allergy. is used to treat allergy of next of partOf In a medical context, "past history of" usually refers to a patient's medical history or medical conditions that they have experienced in the past. This can include chronic diseases, past surgeries or medical procedures, allergies, and other relevant medical information. The healthcare provider will typically ask about a patient's past medical history as part of their overall assessment, in order to gain a more complete understanding of the patient's health status and any potential risk factors. past history of The term "performed by" usually refers to the person who carried out a specific action or procedure. In a medical context, it may refer to the healthcare provider who conducted a particular examination, test, or treatment. For example, a blood test may be performed by a phlebotomist, a surgical procedure may be performed by a surgeon, or a physical exam may be performed by a primary care physician. performed by Indicates that a healthcare professional performed a medical procedure or examination. performs Indicates that a healthcare professional prescribed a medication as part of a treatment plan. prescribed "Present history of" refers to the current medical condition or symptoms that a patient is experiencing at the time of the medical encounter or visit. It includes a detailed description of the patient's current symptoms, including when they began, how they have progressed, and any factors that may have triggered or worsened them. The present history is an essential component of a medical assessment, as it helps the healthcare provider to identify potential causes of the patient's symptoms and develop an appropriate treatment plan. A thorough present history may also include information about the patient's medical history, medications they are currently taking, and any other relevant factors that may be contributing to their current condition. For example, in the case of a patient presenting with chest pain, the present history would include a detailed description of the pain, including its location, intensity, and any associated symptoms such as shortness of breath or nausea. The healthcare provider would also inquire about any past medical history, such as a history of heart disease or high blood pressure, and any medications the patient is currently taking. This information would help the provider to determine the potential cause of the chest pain and develop an appropriate treatment plan. present history of previous of Indicates the disposition of a patient after an encounter or hospital stay. provides disposition for Indicates the source of a referral to a healthcare professional or facility. referral source "Referred by medical professional" refers to the process of a healthcare provider directing a patient to seek care from another healthcare professional or facility for evaluation, diagnosis, treatment, or management of a medical condition. When a patient is referred by a medical professional, it means that their primary care physician or another healthcare provider has determined that the patient's medical needs cannot be adequately addressed within the scope of their own practice, and that additional expertise or resources are required from another healthcare provider or facility. For example, a patient with a complex medical condition may be referred by their primary care physician to a specialist for a more thorough evaluation and treatment. Or a patient may be referred by a physical therapist to an orthopedic surgeon for further evaluation of a musculoskeletal condition. Referrals by medical professionals are an important aspect of healthcare coordination, as they help ensure that patients receive appropriate and timely care from the most appropriate healthcare providers and facilities. referred by It refers to the process of directing a patient to a particular healthcare facility or specialist for further evaluation, treatment, or management of a medical condition. When a patient is referred to a site of care, it means that their primary care physician or another healthcare provider has determined that the patient's medical needs cannot be adequately addressed within the scope of their own practice, and that additional expertise or resources are required. For example, a patient with a suspected heart condition may be referred to a cardiologist for specialized testing and treatment. Or a patient with a complex medical condition may be referred to a tertiary care hospital with the necessary expertise and resources to manage their condition. Referrals to a site of care may be made for a variety of reasons, including: Suspected or confirmed diagnosis of a serious medical condition Need for specialized diagnostic testing or treatment Need for surgery or other medical procedures Chronic medical conditions requiring ongoing management and monitoring referred to Indicates the visit or encounter during which a referral to another healthcare professional or facility was made. referring visit " situated in" refers to the physical location of an organization or institution. It may refer to a hospital, clinic, research center, university, government agency, or any other type of organization that provides services or conducts activities within a specific geographic area. The location of an organization may be important for a variety of reasons, such as accessibility for patients or clients, proximity to other healthcare providers or research facilities, or availability of resources and support services. The location of an organization may also have implications for its funding, staffing, and regulatory requirements, as different regions and jurisdictions may have different laws and policies governing situated in "Surgery performs on" refers to a medical procedure that is performed on a patient by a surgeon or surgical team. The surgery may be performed for diagnostic or therapeutic purposes, such as to remove a diseased or damaged organ or tissue, repair a defect or injury, or alleviate symptoms of a medical condition. Surgery can be performed under general anesthesia, regional anesthesia, or local anesthesia, depending on the type of procedure and the patient's health status. In some cases, minimally invasive or robotic surgery may be used to reduce the amount of tissue damage and recovery time. Before surgery, the patient is evaluated by the surgeon and anesthesia team to determine their suitability for the procedure and to discuss any potential risks or complications. The patient is also given instructions on how to prepare for the surgery and what to expect during the recovery period. After surgery, the patient is closely monitored for any complications and may be given pain medication and other treatments to aid in the healing process. Physical therapy or rehabilitation may also be necessary to regain strength and function. Sources: American College of Surgeons. (n.d.). What Is Surgery? Retrieved from https://www.facs.org/education/patient-education/patient-resources/what-is-surgery surgery performs on surgical history of Indicates the healthcare professional or entity that has a suspicion of a medical condition or diagnosis. suspicion by refers to a healthcare provider's belief or concern that a patient may have a particular medical condition or disease based on their symptoms, physical examination findings, medical history, and diagnostic test results. When a healthcare provider suspects a disease, they may order additional tests or procedures to confirm or rule out the diagnosis. The healthcare provider may also refer the patient to a specialist for further evaluation and management. It is important to note that suspicion of disease does not necessarily mean that the patient has the condition in question, but rather that there is a possibility or likelihood of it. A definitive diagnosis can only be made through appropriate testing and evaluation. suspicion of "System review performs on" refers to a comprehensive evaluation of a patient's major organ systems and functions during a physical examination. The healthcare provider will examine each system individually to assess its overall function and identify any abnormalities that may indicate underlying medical conditions. The systems typically reviewed during a comprehensive physical exam may include the respiratory system, cardiovascular system, gastrointestinal system, neurological system, musculoskeletal system, skin, and others. During a system review, the healthcare provider may perform various tests or procedures, such as listening to the heart and lungs with a stethoscope, checking blood pressure and pulse, examining the abdomen for tenderness or swelling, testing reflexes, and observing the patient's gait and mobility. They may also ask the patient specific questions related to each system, such as whether they experience shortness of breath, chest pain, digestive issues, or other symptoms. system review performs on Indicates the healthcare facility from which a patient was discharged. was discharged from Indicates the healthcare professional who performed a surgical procedure. was operated on by The measurement of a subject's energy expenditure when at rest. (NCI) OpenEMR BMI A patient's energy expenditure at rest. (NCI) Finding of body mass index 'C-reactive protein' is a DataProperty that represents the level of C-reactive protein (CRP) in the blood. CRP is an acute-phase protein produced by the liver in response to inflammation in the body. It is a non-specific marker of inflammation and is often used as an indicator of infection, autoimmune disease, or other inflammatory conditions. The measurement of CRP levels in the blood can help in the diagnosis and monitoring of various diseases, including cardiovascular disease, rheumatoid arthritis, and inflammatory bowel disease. The unit of measurement for CRP is usually milligrams per liter (mg/L) or milligrams per deciliter (mg/dL). C-reactive protein A RT-PCR test report is a document that shows the results of a RT-PCR (reverse transcription-polymerase chain reaction) test. This test is a type of diagnostic test used to detect the presence of genetic material from a specific pathogen, such as a virus, in a person's respiratory or other bodily fluids. The RT-PCR test is commonly used to diagnose viral infections, including COVID-19. The test report typically includes information such as the date and time the test was performed, the type of test performed, the name and identification number of the person tested, and the results of the test. RTPCR test report The "Sig" is the directions to follow by the provider to the patient for a given medication. https://denalirx.com/sig-explanations/ Openclinic SIG Medication : Directions for use or SIG CODE SpO2 stands for peripheral capillary oxygen saturation, which is a measure of the amount of oxygenated hemoglobin in the blood. It is usually measured using a pulse oximeter, a non-invasive device that clips onto a finger or earlobe and uses light to measure the amount of oxygen saturation in the blood. SpO2 is an important measure in monitoring the respiratory function of patients, particularly those with lung or heart conditions. Solismed SpO2 An advance healthcare directive, also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. OnetouchEMR advance directive detail The DataProperty 'age' represents the age of a person or an individual in years. It is a quantitative attribute that describes a characteristic of a person's demographic information. This property can be used in various domains such as healthcare, education, and social science research to analyze data and draw insights based on age-related trends. The 'age' data property can be measured in years, months, or days depending on the level of granularity required by the application or domain. age Antigen-type substances that produce immediate hypersensitivity (HYPERSENSITIVITY, IMMEDIATE). (MSH) 75Health allergen name A substance that causes an allergic response. Examples include pollen, molds, and certain foods. (NCI) A substance that elicits an allergic reaction. (NCI) Products containing allergenic substances used for allergy diagnosis or treatment. (SNOMEDCT_US) The specific details of a patient's allergic condition, including the type of allergy and its severity. allergic condition detail The term "allergy from date" refers to the date when a patient first experienced symptoms of an allergy or the date when a patient was first diagnosed with an allergy. 75Health allergy from date The Data Property 'allergy history ' refers to the specific information related to a patient's history of allergies. It can include the type of allergen(s) the patient is allergic to, the severity of the allergic reaction(s), the date(s) of the reaction(s), and any other relevant information about the patient's allergy history. This information can be used by healthcare professionals to inform treatment plans and prevent future allergic reactions. allergy history The term "allergy medication review" refers to a process of assessing a patient's current medications to identify any that may cause an allergic reaction. It involves reviewing the patient's medical history, medication list, and any known allergies to determine the appropriateness of the medications prescribed. The purpose of the review is to prevent adverse reactions to medications and to ensure that the patient receives the most effective treatment possible. The review is usually conducted by a healthcare provider, such as a physician, pharmacist, or nurse. allergy medication review The term 'allergy reaction detail' can refer to a data property that describes the specific details of an allergic reaction experienced by a patient. This property can include information such as the type of allergy, the severity of the reaction, the symptoms experienced, and any treatment that was administered. It is typically used within the context of a health record or patient encounter to document an allergy and its associated details. Example: A patient's health record indicates that they have a known allergy to penicillin. The 'allergy reaction detail' property includes information on the severity of their previous reaction (moderate), the symptoms they experienced (hives, itching, difficulty breathing), and the treatment that was administered (epinephrine injection). This information is important for healthcare providers to have on hand in case the patient is exposed to penicillin again in the future. allergy reaction detail A quantitative measurement for assessing the amount of glucose present in a blood sample. (NCI) 75Health blood glucose Blood Sugar Patient Health Record vital: Glucose by Glucometer "Blood pressure" can be defined as a data property that refers to the numerical measurement of the pressure exerted by circulating blood on the walls of blood vessels, expressed in millimeters of mercury (mmHg). blood pressure Breathing patterns refer to the respiratory rate, which is defined as the frequency of breaths over a period of time, as well as the amount of air cycled during breathing (tidal volume). Breathing patterns are an important diagnostic criteria for many diseases, including some which involve more than the respiratory system itself. Breathing patterns consist of tidal volume and respiratory rate in an individual. An average breathing pattern is 12 breaths per minute and 500 mL per breath. Eupnea is normal breathing at rest. There are types of altered breathing patterns that are symptoms of many diseases. There are multiple types of normal and abnormal respiration. They include apnea, eupnea, orthopnea, dyspnea hyperpnea, hyperventilation, hypoventilation, tachypnea, Kussmaul respiration, Cheyne-Stokes respiration, sighing respiration, Biot respiration, apneustic breathing, central neurogenic hyperventilation, and central neurogenic hypoventilation. Each pattern is clinically important and useful in evaluating patients. This activity covers the essential features of abnormal respiration and highlights the role of the interprofessional team in caring for patients affected by these conditions. Solismed breathing pattern The term 'clinical exam observation' generally refers to the physical and objective assessment of a patient's health status by a medical professional during a clinical examination. This observation can include a variety of measurements such as blood pressure, temperature, heart rate, and respiratory rate, as well as visual inspections of the body, such as looking at the skin or listening to the lungs with a stethoscope. The observations made during a clinical examination are used to help diagnose medical conditions and to monitor a patient's health status over time. clinical examination observation "An after-visit summary that provides a patient with relevant and actionable information and instructions containing the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms." EHRMDS clinical summary "date" is a data type that represents a specific point in time, typically expressed as a combination of year, month, and day. It can also include information such as the time of day, time zone, and daylight saving time status. date The date on which a patient is admitted to a hospital or healthcare facility. date of admission The date on which a patient is discharged from a hospital or healthcare facility. date of discharge In the context of healthcare, "details" usually refers to specific information or facts about a patient's condition, medical history, treatment plan, medications, or other related aspects of their care. These details may include things like test results, vital signs, lab values, symptoms, diagnoses, procedures, and more. Having accurate and up-to-date details about a patient is important for effective communication and collaboration among healthcare providers, as well as for ensuring safe and appropriate care. In healthcare information systems, "details" may also refer to specific data elements or attributes that are captured and stored as part of a patient's electronic health record. detail A diagnosis code is a code used to identify a specific disease, disorder, or medical condition. It is typically a series of alphanumeric characters that are used to describe a patient's diagnosis for medical billing, research, and statistical purposes. Diagnosis codes are used in medical coding to ensure that a patient's diagnosis is properly documented and communicated across the healthcare system. Some common classification systems for diagnosis codes include the International Classification of Diseases (ICD) and the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT). EHRMDS diagnosis code A diagnosis code name is a label or descriptor assigned to a specific medical condition, disease, or disorder. These codes are used to classify and identify diagnoses in medical records, billing systems, and insurance claims processing. Diagnosis code names are standardized according to various coding systems, such as the International Classification of Diseases (ICD) and the Current Procedural Terminology (CPT) code sets. EHRMDS diagnosis code name This property refers to the detailed information about the diagnosis of a patient's medical condition, including the name of the condition, any relevant diagnostic tests or procedures that were performed, and any other relevant information related to the diagnosis. It can also include information about the severity of the condition, the stage at which it was diagnosed, and any other relevant details that can help in providing better treatment to the patient. diagnosis detail SCTID 271650006 SNOMED CT diastolic blood pressure The amount of medicine taken, or radiation given, at one time. (NCI) EHRMDS dose A quantity of an agent (such as substance or energy) administered, taken, or absorbed at one time. (NCI) Specified quantity of a medicine, to be taken at one time or at stated intervals. [ISO 11615:2012 Health Informatics] (NCI) The amount of study drug (or placebo) administered to a patient or test subject to be taken at one time or at stated intervals. (NCI) Use for measured amounts of chemicals. (CSP) A unique numeric code assigned by the U.S. Food and Drug Administration to prescription drugs and insulin products manufactured, prepared, processed, or propagated by registered establishments for commercial distribution. U.S. prescription drugs must use an NDC; most non-prescription drugs are also primarily referenced by NDC. NDC codes change often as companies merge, new products are introduced, and drugs are retired. Each code is a unique 10-digit, 3-segment number in one of the following configurations: 4-4-2, 5-3-2, or 5-4-1. The first, labeler code segment is assigned by the FDA to identify the establishment. The second, product code segment identifies a specific strength, dosage form, and formulation for a particular firm. The third, package code segment identifies package sizes and types. Both the product and package codes are assigned by the establishment. An asterisk may appear as a placeholder in the second or third segments. (NCI) EHRMDS drug code Date of encounter EHRMDS encounter date visit date Number of encounter. It must be ensured that the no encounter number is arbitrarily assigned. EHRMDS encounter number A Patient Encounter describes an interaction between a Patient and a healthcare provider. Types of Encounter can be: Appointments, Inpatient Stay, Outpatient Visit, Patient's General Practitioner Visit, Telephone Consultation, Hospital Encounter, Appointment, Office Visit encounter type A family history, as related to medicine, is a record of the diseases and health conditions of an individual and that person's biological family members, both living and deceased. The past occurrences (of a medical or mental health condition) in family members or past incidences (of a type of behavior) by family members. family history Followup is the act of making contact with a patient or caregiver at a later, specified date to check on the patient's progress since his or her last appointment. Appropriate followup can help you to identify misunderstandings and answer questions, or make further assessments and adjust treatments. In addition, followup helps to promote a good working relationship between you and your patients. For example, you can follow up to: Monitor health. Reinforce knowledge and action plans. Confirm medicine regimens. Schedule appointments. Verify followthrough on referrals. Share lab results. GNUMed followup date The number of doses administered per a specific interval. (NCI) EHRMDS frequency The number of times a substance is administered within a specific time period. (NCI) Treatment goal to achieve 75Health goal The statement "had COVID test" can be modeled using a data property such as COVID test status with possible values like "positive," "negative," "pending," or "not tested." had covid test Followup is the act of making contact with a patient or caregiver at a later, specified date to check on the patient's progress since his or her last appointment. Appropriate followup can help you to identify misunderstandings and answer questions, or make further assessments and adjust treatments. In addition, followup helps to promote a good working relationship between you and your patients. For example, you can follow up to: Monitor health. Reinforce knowledge and action plans. Confirm medicine regimens. Schedule appointments. Verify followthrough on referrals. Share lab results. has followup A circumferential measurement of the head at the widest point. (NCI) SCTID 363812007 OpenEMR SNOMED CT head circumference A circumferential measurement of the head at the widest point, which is traditionally above the eyebrows. (NCI) Health Trend refers to changes in the level of certain disease state compared with the previous days. Solismed health maintenance summary Health Trend Summary The distance from the sole to the crown of the head with body standing on a flat surface and fully extended. (MSH) Solismed height Clinical Exam Height (cms) The distance from the base to the top of a subject's entire body. (SNOMEDCT_US) The vertical measurement or distance from the base to the top of a subject or participant. (NCI) History generally refers to the study of past events and their impact on society, culture, politics, and other aspects of human life. In a medical context, history refers to a patient's past medical history, including any previous illnesses, surgeries, hospitalizations, or medical treatments they have undergone. Taking a thorough patient history is an essential part of the diagnostic process and can provide important clues about a patient's current health status and potential risk factors. history "Hospital name" is a string-valued property that represents the name of a hospital. It is typically used in healthcare information systems to identify the hospital where a patient received treatment or a procedure was performed. The property can be associated with various entities, such as patient records, clinical encounter records, or billing records. hospital name An image typically refers to a visual representation of an object or a body part obtained through diagnostic imaging procedures like X-rays, MRI scans, CT scans, etc. These images are usually captured and stored digitally for further analysis by healthcare professionals. image An immunization record is a comprehensive timeline of all vaccinations a patient has received. immunization history Implant history refers to the record of any medical device or implant that a patient has had placed in their body during a previous medical procedure. This record typically includes the type of implant, the date of the procedure, the location of the implant, and any relevant details about the implant, such as its serial number or expiration date. The implant history is an important part of a patient's medical record and is used by healthcare providers to ensure that patients receive appropriate care and follow-up related to their implants. implant history "Implant name" refers to the specific type or brand name of a medical device or implant that has been surgically placed in a patient's body to treat or manage a medical condition. Examples of implants include artificial joints, pacemakers, and breast implants. The implant name is typically included in the patient's medical records and is used to track the type and location of the implant for future reference. implant name An outcome of a physical examination as part of a Clinical Investigation. EHRMDS investigation result The specific details of a laboratory finding, including the test name, result, and any other relevant information. lab finding detail The name of a laboratory test performed on a patient. lab test name Order for any service provided by a laboratory that could not be provided by a nonlaboratory. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_1_CPOE_MedicationOrders.pdf SCTID 721965002 SNOMED CT Solismed laboratory order Lab Order A medical specialty is a branch of medical practice that is focused on a defined group of patients, diseases, skills, or philosophy. Examples include children, cancer, laboratory medicine, or primary care. GNUHealth medical speciality A company licensed to discover, develop, market and distribute drugs. (NCI) 75Health medication company name The data property "medication end date" typically refers to the date when a medication or treatment is intended to be completed or stopped. This information is often recorded in a patient's health record to help healthcare providers manage their care plan and ensure that they receive the appropriate treatment for their condition. For example, a patient with a bacterial infection may be prescribed antibiotics for a specific duration, such as ten days. The medication end date would then be recorded as the date when the course of antibiotics should be completed, to ensure that the infection is fully treated and the patient does not develop antibiotic resistance. 75Health medication end date "NCI-GLOSS Definition: A legal drug that is used to prevent, treat, or relieve symptoms of a disease or abnormal condition. ACC/AHA Definition: A drug product that contains one or more active and/or inactive ingredients; it is intended to treat, prevent or alleviate the symptoms of disease. This term does not refer to the individual ingredients that make up the product. CDISC-GLOSS Definition: A finished dosage form, for example, tablet, capsule, solution, etc., that contains an active drug ingredient generally, but not necessarily, in association with inactive ingredients. The term also includes a finished dosage form that does not contain an active ingredient but is intended to be used as a placebo. https://ncithesaurus.nci.nih.gov/ncitbrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&version=20.01d&code=C459&ns=ncit" EHRMDS medication name The data property 'medication start date' refers to the date when a patient began taking a medication as part of their treatment plan. This data property records the start date of the medication and is important to keep track of the patient's medication history and to monitor the effectiveness of the medication. 75Health medication start date A gynaecological history is an assessment of the female reproductive system. menstrual history The data property "name" typically refers to the given name or full name of an individual, organization, or other entity. It is a textual representation used to identify a person or object, and it is commonly used in various contexts such as healthcare, finance, and legal documentation. For example, in a healthcare setting, the name data property may be used to identify a patient, healthcare provider, or medical facility. The value of the "name" data property may be a string of characters, and it may include letters, numbers, and symbols. name The medical history of a patient related to pregnancy and childbirth, including any previous pregnancies, deliveries, or complications. obstetric history Number of days since the start of symptoms or hospitalization offset Data property 'other treatment plan detail' refers to a property that can be used to describe any additional details or instructions related to a patient's treatment plan that are not covered by other specific data properties. This may include information such as the frequency or duration of treatment, any special precautions or considerations, or any other relevant details that may be necessary for the proper execution of the treatment plan. other treatment plan detail Past history includes an inquiry into the patient's past health. past history A pathology order is a request by a healthcare provider for a pathology test or examination of a patient's tissues or bodily fluids to aid in the diagnosis and management of a medical condition. It is a formal request that includes specific details about the type of test or examination that needs to be performed, the samples that need to be collected, and the reason for the request. Pathology orders are usually generated electronically and transmitted to the laboratory or imaging center where the test will be conducted. Solismed pathology order A patient ID is a unique identifier assigned to an individual by a healthcare organization to track their medical information and history. It is used to distinguish one patient from another and is typically a combination of letters and numbers. Patient IDs are crucial for accurate medical record keeping and ensure that a patient's medical information is easily accessible and identifiable by healthcare providers. patient ID Growth charts consist of a series of percentile curves that illustrate the distribution of selected body measurements in children. Pediatric growth charts have been used by pediatricians, nurses, and parents to track the growth of infants, children, and adolescents in the United States since 1977. Pediatrics growth chart is a tool used by healthcare professionals to track and monitor a child's growth and development over time. It typically includes measurements such as weight, height or length, head circumference, and other physical characteristics, which are plotted on a graph that shows how the child's growth compares to other children of the same age and gender. This information can be used to identify any potential health issues or developmental delays, as well as to monitor the effectiveness of any interventions or treatments that are implemented. GNUHealth pediatrics growth chart medical specialty dealing with the development and care of children and with the diagnosis and treatment of childhood diseases. pediatrics history A collection of information about a person's health that allows the person to manage and track his or her own health information. A personal history may include information about allergies, illnesses, surgeries, immunizations, and results of physical exams, tests, and screenings. personal history an examination of the bodily functions and condition of an individual physical examination observation The position or physical attitude of the body. (MSH) GNUMed posture The spatial property of a body; where it is or the way in which it is situated. (NCI) Present history includes an inquiry into the patient's present health. present history processName The pulse rate is a measurement of the heart rate, or the number of times the heart beats per minute EHRMDS pulse rate Clinical Exam Pulse Rate Order for any imaging services that uses electronic product radiation. The EP can include orders for other types of imaging services that do not rely on electronic product radiation in this definition as long the policy is consistent across all patient and for the entire EHR reporting period. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/downloads/Stage2_EPCore_1_CPOE_MedicationOrders.pdf Solismed radiology order "Reason for visit" typically refers to the primary complaint or reason why a patient seeks medical attention or visits a healthcare provider. This can include a range of concerns, from acute symptoms like pain or fever, to ongoing chronic conditions, routine check-ups or preventive care, and even mental health concerns. Understanding the reason for a patient's visit is an important step in providing appropriate and effective care. reason for visit The number of refills permitted for a prescribed medication. (NCI) OpenEMR refill The respiration rate is the number of breaths a person takes per minute. The rate is usually measured when a person is at rest and simply involves counting the number of breaths for one minute by counting how many times the chest rises. Respiration rates may increase with fever, illness, and other medical conditions. When checking respiration, it is important to also note whether a person has any difficulty breathing. Normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute. OpenMRS respiratory rate Clinical Exam Respiration Rate The various ways of administering a drug or other chemical to a site in a patient or animal from where the chemical is absorbed into the blood and delivered to the target tissue. (MSH) EHRMDS route Designation of the part of the body through which or into which, or the way in which, the medicinal product is intended to be introduced. In some cases a medicinal product can be intended for more than one route and/or method of administration. (NCI) a mental condition or physical feeling resulting from stimulation of a sense organ or from internal bodily change, as cold or pain. NoshEMR sensitive level Serum ferritin is a blood test that measures the amount of ferritin in the blood. Ferritin is a protein that stores iron in the body. The level of serum ferritin is an important indicator of iron stores in the body and is often used to diagnose and monitor iron deficiency anemia. It can also be elevated in conditions such as inflammation, infection, liver disease, and certain types of cancer. serum ferritin In medicine, a social history (abbreviated "SocHx") is a portion of the medical history (and thus the admission note) addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant. social history In the context of healthcare, 'special instruction' refers to specific guidelines, directions or recommendations given by a healthcare provider to a patient. These instructions are usually given to the patient or their caregiver as a way of ensuring that they follow certain precautions or steps to manage their condition or treatment properly. Special instructions can relate to different aspects of care, such as medication management, wound care, diet, exercise, or follow-up appointments, and can help improve patient outcomes and overall quality of care. special instruction The content of an active ingredient expressed quantitatively per dosage unit, per unit of volume, or per unit of weight, according to the pharmaceutical dose form. (NCI) EHRMDS strength summary A history of the surgical procedures that a particular person has had, and complications therefrom, if any. surgical history "Survived" generally means that a person or organism has overcome a difficult or dangerous situation, such as a life-threatening illness or injury, and has continued to live or exist. It is commonly used in medical contexts to describe a patient who has recovered from a serious illness or injury. In a broader sense, it can also refer to an individual who has overcome other challenges or adversities, such as a natural disaster or personal hardship. survived The specific details of a system review, including any abnormalities or relevant findings. system review detail SCTID 271649006 SNOMED CT systolic blood pressure The recorded body temperature of a patient, usually measured in degrees Celsius or Fahrenheit. EHRMDS temperature Clinical Exam Temperature (°C) bodysite from where temperature has taken. EHRMDS temperature source Clinical Exam Temperature Source The term "treatment plan investigation" refer to the process of conducting further tests or procedures to investigate and evaluate the effectiveness of a treatment plan that has been prescribed to a patient. This may involve ordering laboratory tests, imaging studies, or other diagnostic procedures to assess the patient's response to treatment and adjust the treatment plan accordingly. treatment plan investigation "The glucose urine test measures the amount of sugar (glucose) in a urine sample. The presence of glucose in the urine is called glycosuria or glucosuria. Glucose level can also be measured in other bodily fluids using a blood test or a cerebrospinal fluid test. The normal amount of glucose in urine is 0 to 0.8 mmol/L (millimoles per liter)." GNUMed urine sugar SCTID 276361009 The measurement around the body at the level of the ABDOMEN and just above the hip bone. The measurement is usually taken immediately after exhalation. (MSH) OpenEMR SNOMED CT waist circumference A circumferential measurement of the waist, which may be classified as the area immediately below the lowest rib, at the narrowest part of the torso, midpoint between the lowest rib and the iliac crest, or immediately above the iliac crest. (NCI) The distance around an individual's midsection or waist. (NCI) A measurement that describes the vertical force exerted by a mass of the patient as a result of gravity. (NCI) The mass or quantity of heaviness of an individual. It is expressed by units of pounds or kilograms. (MSH) OpenEMR weight Clinical Exam Weight (kgs) The weight of a subject. (NCI) A visit by a patient or study participant to a medical professional. Patient Visit (NCI) Finding from the procedure that involves testing or manipulating a sample of blood, urine, or other body substance in a laboratory setting. (NCI) Finding from a medical procedure that involves testing a sample of blood, urine, or other substance from the body. Tests can help determine a diagnosis, plan treatment, check to see if treatment is working, or monitor the disease over time. LaboratoryTest LNC:LA26428-5 Family history LNC:LP120715-0 Body part LNC:LP63617-2 Menstrual History LNC:LP64610-6 History of present illness LNC:MTHU014081 Social history LNC:MTHU017829 Body site LNC:MTHU034880 Type of encounter Body temperature finding Laboratory test finding A hospital is a healthcare facility that provides medical care and treatment to patients who require more advanced and specialized care than can be provided in a clinic or doctor's office. Hospitals typically have a larger staff of healthcare professionals, including doctors, nurses, and specialists, and offer a wider range of services than clinics or other outpatient facilities. Hospitals can vary in size and scope, from small community hospitals to large academic medical centers. Some hospitals may specialize in particular types of medical care, such as cancer treatment or pediatric care, while others may provide a full range of services. Hospitals may also have different departments or units, such as emergency departments, intensive care units, and surgical units, to provide specialized care to patients with different needs. (Source: MedlinePlus, https://medlineplus.gov/hospitals.html) UMLS CUI: C1266869 Hospital Severity Obstetric history refers to a woman's history of past pregnancies, including the number of pregnancies, the outcome of each pregnancy (such as live birth, stillbirth, or miscarriage), and any pregnancy-related complications or medical conditions. Obstetric history is important for several reasons. First, it can help healthcare providers determine a woman's risk for certain pregnancy-related complications, such as preterm labor or preeclampsia. Second, it can help healthcare providers identify any underlying medical conditions or risk factors that may require closer monitoring or treatment during pregnancy. (Source: American College of Obstetricians and Gynecologists, https://www.acog.org/womens-health/faqs/obstetric-history-and-examination) Obstetric history A clinic is a medical facility or healthcare institution that provides outpatient medical care and treatment to patients. Clinics can vary in size and scope, and may specialize in a particular type of medical care or serve a particular population, such as women's health clinics or pediatric clinics. Clinics may be run by a single healthcare provider or a team of providers, and may offer a range of services, such as preventive care, diagnosis and treatment of acute and chronic illnesses, and referrals to specialists or other healthcare professionals. (Source: MedlinePlus, https://medlineplus.gov/ency/article/002258.htm) Clinic Status Gender Sensitivity Procedure by site Finding of blood group Pathological process Medical specialty History of recreational drug use refers to a person's past use of drugs for non-medical purposes, such as to alter one's mood, perception, or consciousness. Recreational drugs can include illegal substances such as cocaine, heroin, and marijuana, as well as legal substances such as alcohol and tobacco. (Source: National Institute on Drug Abuse, https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/what-drug-addiction-treatment) SCTID 407586004 SNOMED CT History of recreational drug use H/O: recreational drug use Region Site of care Risk factor Body System Finding Substance pharmaceutical preparation BFO:0000015 A sequence of events which produces some outcome. (NCI) A sequence or flow of activities in an organization with the objective of carrying out work. Tasks are atomic activities that are included within a process. [NCI] (NCI) UMLS CUI: C4521054 Process GEO:000000372 A geographical entity that is demarcated at least in part by one or more closed fiat boundaries all of whose lines are part of the planetary surface. geographical region HP:0012393 An allergy is an immune response or reaction to substances that are usually not harmful. Allergy HP:0410323 Drug allergy HP:0500094 Latex allergy is an IgE-mediated immediate hypersensitivity response to natural rubber latex (NRL) protein with a variety of clinical signs ranging from contact urticaria, angioedema, asthma, and anaphylaxis. Latex allergy IDO:0000586 A part of an extended organism that itself has as part a population of one or more infectious agents and that (1) exists as a result of processes initiated by members of the infectious agent population and is (2) clinically abnormal in virtue of the presence of this infectious agent population, or (3) has a disposition to bring clinical abnormality to immunocompetent organisms of the same Species as the host (the organism corresponding to the extended organism) through transmission of a member or offspring of a member of the infectious agent population. Infection NCIT:C25457 A state of being, such as a state of health. Condition OGMS:0000014 Clinical finding OGMS:0000020 A process experienced by the patient, which can only be experienced by the patient, that is hypothesized to be clinically relevant. Symptom OGMS:0000029 A physical sign in which a non-zero value is standardly considered to be an indication that the organism is alive. Vital sign OGMS:0000031 A disposition (i) to undergo pathological processes that (ii) exists in an organism because of one or more disorders in that organism. Disease OGMS:0000073 XAO:0003186 A region of the whole organism that contains a recognizable set of structures or anatomical entities. anatomical region OCHV:C0332119 past history OCHV:C0424945 personal history history of allergies allergy history history surgical history of immunization A diagnostic procedure is a medical test, exam or procedure that is performed to determine the cause or nature of an illness, injury or medical condition. It is used to identify the presence, extent, or severity of a disease or medical condition. Source: MedlinePlus, U.S. National Library of Medicine Diagnostic procedure "Any matter of defined composition that has discrete existence, whose origin may be biological, mineral or chemical. (NCI)" Substance owl:Thing A group of people who work together. Organization An organizational unit is a unit within an organization that performs specific functions or roles. It is typically a sub-unit of a larger organization and is responsible for a specific set of tasks or activities. Organizational units can be based on different criteria such as geography, function, product or service line, customer type, or business process. They can also be structured hierarchically, with smaller units reporting to larger ones, or functionally, with units focused on specific functions or processes. The purpose of organizing a business into units is to create a more efficient and effective structure that facilitates the achievement of organizational goals. Organizational unit The foaf:Agent class is the class of agents; things that do stuff. Agent A human being. (NCI) A human being. EXAMPLE(S): OTHER NAME(S): NOTE(S): (NCI) A living subject of the species homo sapiens. (HL7V3.0) Human beings in general. (NCI) Person CONTSONTO:health_record data repository regarding the health and healthcare of a subject of care health_record "Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. (MSH) A patient is the subject of observations. (NCI) A person who receives medical attention, care, or treatment, or who is registered with medical professional or institution with the purpose to receive medical care when necessary. (NCI) Patient The signs of life that may be monitored or measured, namely pulse rate, respiratory rate, body temperature, and blood pressure. (MSH) Vital signs (such as height, weight, and blood pressure) directly measure an individual's current state of attributes. (NCI) Vital sign opencare:AllergicDisposition A propensity to developing a pathological immune process generally directed towards a foreign antigen, which results in tissue injury. It is most often applied to type I hypersensitivity but other hypersensitivity types especially type IV (e.g. allergic contact dermatitis) may be involved. Revised nomenclature for allergy for global use:Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003. (SNOMEDCT_US) The disposition to develop an allergic reaction. (SNOMEDCT_US) Allergic disposition Allergy opencare:AllergyHistory Allergy history refers to a person's medical history of allergic reactions to various substances or environmental factors, such as pollen, dust, certain foods, medications, or insect bites. The allergy history may include information on the types of allergic reactions a person has experienced, the severity of the reactions, and the treatment that was received. Knowing a person's allergy history can help healthcare providers make accurate diagnoses and develop appropriate treatment plans, as well as take precautions to avoid potential allergic reactions during medical procedures or interventions. It is important for individuals to keep track of their own allergy history and inform their healthcare providers of any known allergies, as well as any family history of allergies, to ensure the safest and most effective medical care. (Source: American Academy of Allergy, Asthma, and Immunology, https://www.aaaai.org/conditions-and-treatments/library/allergy-library/allergy-history) EHRMDS Allergy history opencare:AllergySensitivity Allergy sensitivity opencare:AlliedHealthProfessional A healthcare professional who is not a physician, nurse or dentist, but who is trained and licensed to provide healthcare services. They work in various areas including rehabilitation, diagnostic testing, therapeutic services, and patient education. (Source: American Public Health Association) Allied health professional opencare:AnatomicalRegion A general term for grouping regions of the body; preference is to use NTs. (CSP) Anatomical areas of the body. (MSH) Named areas of the body. (NCI) Anatomical region Body site or region opencare:Anesthesiologist An Anesthesiologist is a medical doctor who specializes in administering anesthesia to patients undergoing surgery or other medical procedures. They are responsible for ensuring the patient's safety and comfort during the procedure and may also be involved in the management of pain after the procedure. Anesthesiologists work closely with other healthcare professionals, including surgeons, nurses, and other medical specialists, to provide optimal care to patients. Source: American Society of Anesthesiologists. (2021). What is an Anesthesiologist? Retrieved from https://www.asahq.org/about-asa/asa-history-and-timeline/asa-history-and-timeline-detail/what-is-an-anesthesiologist Anesthesiologist opencare:Animal A state of being, such as a state of health. (NCI) An observable finding or state that persists over time and tends to require intervention or management, and, therefore, distinguished from an Observation made at a point in time; may exist before an Observation of the Condition is made or after interventions to manage the Condition are undertaken. Examples: equipment repair status, device recall status, a health risk, financial risk, public health risk, pregnancy, health maintenance, chronic illness (HL7V3.0) Animal opencare:Bacteria A large group of single-cell microorganisms. Some cause infections and disease in animals and humans. The singular of bacteria is bacterium. (NCI) A unicellular, prokaryotic organism that reproduces by cell division and usually has cell walls; can be shaped like spheres, rods, or spirals; and can be found in virtually any environment. (NCI) Any organism assigned to the kingdom Bacteria. (NCI) Unicellular, prokaryotic organisms that reproduce by cell division and usually have cell walls; can be shaped like spheres, rods or spirals and can be found in virtually any environment. (NCI) Bacteria opencare:BloodGroup An inherited feature on the surface of the red blood cells. A series of related blood types constitutes a blood group system, such as the Rh or ABO system. https://www.medicinenet.com/blood_group/definition.htm EHRMDS Blood group opencare:BodyPart Anatomical structure, each instance of which has as its constitutional part some subdivision of the skeleton, and some subdivision of integument, such that the meronymic sum of an individual's cardinal body parts constitutes the individual's entire body. Examples: head, limb (FMA) Anatomical structure, which consists of a maximal set of diverse subclasses of organ and organ part spatially associated with either the skull, a segment of the vertebral column or a complete set of bones of the appendicular skeleton; it is partially surrounded by skin and forms a distinct morphological subdivision of the body; together with all other body parts, a body part constitutes the human body. Examples: Canonical instances are limited to head, neck, trunk, and the limbs. (UWDA) Any part of an organism. (NCI) Example:Abdomen, Eye, Elbow, Brain, Hair, Ear, Finger, Hand etc Parts of the human body viewed from a philosophical or social perspective. (MSH) Body part opencare:BodySite The Body Site dictionary is used to indicate body locations where an immunization or medication is administered. Body Location or Region, HL7 version 2.x Body site used in chapter(s) 4; HL7 table 0163 (HL7V3.0). Example: left upper forearm, Left vastus lateralis, left ventral gluteal, nebulized body site, Perianal, right antecubital fossa, right anterior chest, Right arm, Right deltoid, Right ear structure, Right external jugular vein, Right eye, Right gluteus medius, Right internal jugular vein, Right Lower Forearm, right mid-forearm, right naris, right posterior chest, right subclavian,, Right upper arm structure, right upper forearm, Right vastus lateralis, etc. Body site opencare:BodySystem An anatomical structure that consists of organs and organ subclasses responsible for certain body functions. Representative examples are the gastrointestinal system, urinary system, and hematopoietic system. (NCI) Eg. : Central Nervous System, Clinical Events Body System or Organ Class, Clinical Observations Body System or Organ Class, Endocrine system, Entire autonomic nervous system, Entire body system, Entire hematological system, Entire immune system, Entire parasympathetic nervous system, Entire peripheral nervous system, Entire reproductive system, Exocrine system, Fascial system, Gastrointestinal system, Genital system, Genitourinary system, Hematological system, Hematopoietic and Lymphatic System, Hematopoietic System, Immune system, Integumentary system, Lymphatic System etc. Anatomical structure, each instance of which has as its direct parts instances of one or more organ types which are interconnected with one another by zones of continuity. Examples: nervous system, cardiovascular system, alimentary system. (FMA) Anatomical structure, which consists of members of predominantly one organ subclass; these members are interconnected by zones of continuity. Examples: skeletal system, cardiovascular system, alimentary system. (UWDA) Body system opencare:BodyTemperature A measurement of the temperature of the body. (NCI) Functions involved in regulating the core temperature of the body. (ICF) The measure of the level of heat of a human or animal. (MSH) Body temperature opencare:Cardiologist Cardiologist: A cardiologist is a medical doctor who specializes in diagnosing and treating conditions related to the heart and blood vessels. This includes conditions such as heart disease, arrhythmias, and heart attacks. They also perform procedures such as angioplasty and heart surgery. Source: https://www.heart.org/en/health-topics/heart-attack/about-heart-attacks/what-is-a-cardiologist Cardiologist opencare:CardiothoracicSurgeon A medical doctor who specializes in surgical procedures of the heart, lungs, esophagus, and other organs in the chest cavity. They perform surgeries to treat a range of conditions such as coronary artery disease, lung cancer, and heart defects. (Source: Cleveland Clinic - https://my.clevelandclinic.org/departments/heart/depts/cardiothoracic-surgery) Cardiothoracic surgeon opencare:CertifiedNurseMidwife A licensed healthcare professional who specializes in providing care to women during pregnancy, childbirth, and the postpartum period. They provide a range of services including prenatal care, labor and delivery management, and gynecological care. [Source: https://www.nursepractitionerschools.com/faq/what-is-a-certified-nurse-midwife] Certified nurse midwife opencare:CertifiedRegisteredNurseAnesthetist A CRNA is a registered nurse who has completed specialized training in anesthesia and has passed a national certification exam. They are licensed to administer anesthesia and are responsible for monitoring the patient's vital signs during surgery or other medical procedures. [Source: American Association of Nurse Anesthetists] Certified registered nurse anesthetist opencare:ChemoTherapy Chemotherapy, also known as chemo, is a medical treatment that uses drugs or medications to kill or stop the growth of cancerous cells or tumors. It is used to treat various types of cancer and some noncancerous conditions. Source: National Cancer Institute Chemo therapy opencare:City A city is a large and densely populated urban area that is often the center of government, commerce, culture, and other important activities within a region. Cities are typically characterized by a high concentration of buildings, infrastructure, and people, and can range in size from small towns to large metropolises. Cities may offer a variety of opportunities and resources to their residents, such as employment, education, healthcare, entertainment, and social and cultural activities. They may also face unique challenges, such as managing population growth, providing adequate infrastructure and services, and ensuring public safety. (Source: United Nations, https://unstats.un.org/unsd/classifications/Econ/geoareas/pdf/Chapter_2_Cities.pdf) City opencare:ClinicalExamination "The act of measuring, questioning, evaluating, or otherwise observing a patient or a specimen from a patient in healthcare; the act of making a clinical judgment. The result, answer, judgment, or knowledge gained from the act of observing a patient or a specimen from a patient in healthcare." Clinical examination opencare:ClinicalFinding "Objective evidence of disease perceptible to the examining healthcare provider. (NCI)" A Clinical Finding is a CLINICAL INVESTIGATION RESULT ITEM. A Clinical Finding represents the PATIENT DIAGNOSIS and symptoms of the PATIENT. For example: Asthma (disorder) Headache (Finding) Clinical, laboratory or molecular evidence, or absence of evidence of disease. Clinical finding opencare:ClinicalLaboratoryScientist A healthcare professional who performs laboratory tests and analyzes results to diagnose and treat diseases. They work in a variety of laboratory settings. Clinical laboratory scientist opencare:ClinicalPharmacist A clinical pharmacist is a pharmacist who works in a healthcare setting, such as a hospital or clinic, and provides specialized patient care services. They work closely with healthcare providers to ensure that patients receive appropriate medication therapy. [Source: American College of Clinical Pharmacy] Clinical pharmacist opencare:ClinicalProfessional The term "clinical professional" is a broad term that can refer to a wide range of healthcare professionals who are involved in providing clinical care to patients. This may include physicians, nurses, nurse practitioners, physician assistants, pharmacists, physical therapists, occupational therapists, speech-language pathologists, clinical psychologists, social workers, and others. These professionals work together to diagnose, treat, and manage various health conditions and promote overall wellness in their patients. Clinical professional Medical professional opencare:Comorbidity Coexistence of two or more physical and/or mental disorders. (PSY) The coexistence of two or more disease processes. (NCI) The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. (MSH) UMLS CUI: C0009488 Comorbidity opencare:Condition In medicine, the term "condition" refers to a particular state or situation that affects the health or well-being of an individual. It can refer to a physical or mental state, illness, disease, or disorder that is diagnosed by a healthcare professional. A medical condition may be acute or chronic, and it can have a wide range of symptoms that may vary in severity and duration. It can also be caused by various factors, such as genetics, lifestyle, environmental factors, infections, injuries, or other medical conditions. Examples of medical conditions include diabetes, high blood pressure, asthma, depression, cancer, arthritis, and many others. A medical condition can be managed or treated with medication, surgery, lifestyle changes, or other forms of therapy, depending on the underlying cause and severity of the condition. Condition opencare:ConservativeTherapy Conservative theraphy helps to manage or improve the symptoms or functionality and promote quality of life without surgery or operation. i.e., Physical therapy, Pain management, Physiatry, Complementary medicine, Weight management, Stress management, Biofeedback, Heat/ice therapy. Conservative management is a type of medical treatment defined by the avoidance of invasive measures such as surgery or other invasive procedures, usually with the intent to preserve function or body parts. For example, in appendicitis, conservative management may include watchful waiting and treatment with antibiotics, as opposed to surgical removal of the appendix. Onetouchemr Conservative therapy opencare:Country A collective generic term that refers here to a wide variety of dependencies, areas of special sovereignty, uninhabited islands, and other entities in addition to the traditional countries or independent states. (NCI) A sovereign nation occupying a distinct territory and ruled by an autonomous government. (NCI) Countries of the world. (HL7V3.0) Country opencare:DentalProcedure Any of the dental diagnostic, preventive, and restorative services provided to meet the needs of a patient. (NCI) The total of dental diagnostic, preventive, and restorative services provided to meet the needs of a patient (from Illustrated Dictionary of Dentistry, 1982). (MSH) UMLS CUI: C0011331 UMLS Dental procedure Dental Treatment opencare:Dermatologist A dermatologist is a medical doctor who specializes in diagnosing and treating conditions related to the skin, hair, and nails. This includes conditions such as acne, psoriasis, and skin cancer. They also perform procedures such as mole removal and skin biopsies. Source: https://www.aad.org/public/diseases/why-see-dermatologist Dermatologist opencare:Diagnosis Diagnosis refers to the identification of a medical condition or disease based on an analysis of symptoms, medical history, physical examination, and medical tests. The process of diagnosis allows healthcare providers to determine the underlying cause of a patient's symptoms and develop an appropriate treatment plan. Sources: The definition of diagnosis is widely recognized in the medical community and is based on common usage in healthcare settings. Example: When a patient presents with symptoms such as chest pain and shortness of breath, a healthcare provider may perform a physical examination, review the patient's medical history and perform diagnostic tests such as an electrocardiogram (ECG) or blood tests to identify the cause of the symptoms. Based on the results of the examination and tests, the healthcare provider may diagnose the patient with a heart condition such as angina or a heart attack, and develop an appropriate treatment plan to address the condition. The representation of a conclusion of a diagnostic process. Diagnosis opencare:DiagnosisType "DiagnosisType" is a term used in the context of electronic health records (EHRs) and refers to the categorization or classification of a patient's medical condition or disease. In EHRMDS, DiagnosisType is further classified into different types of diagnoses, including Provisional, Final, Admission, Interim, Working, and Discharge. Provisional Diagnosis: A provisional diagnosis is a tentative diagnosis that is made based on the available information at the time of examination. This diagnosis is subject to change based on further investigation or the patient's response to treatment. Final Diagnosis: A final diagnosis is made after all diagnostic tests, procedures, and investigations have been completed, and all relevant information has been gathered. This diagnosis is considered definitive and forms the basis for treatment and management of the patient's condition. Admission Diagnosis: An admission diagnosis is the primary diagnosis given to a patient when they are admitted to a hospital or healthcare facility. Interim Diagnosis: An interim diagnosis is a diagnosis made during ongoing treatment and management of a patient's condition. This diagnosis is subject to change based on the patient's response to treatment. Working Diagnosis: A working diagnosis is a preliminary diagnosis that is based on the clinician's initial assessment of the patient's symptoms and medical history. This diagnosis is subject to change based on further investigation or the patient's response to treatment. Discharge Diagnosis: A discharge diagnosis is the diagnosis given to a patient when they are discharged from a healthcare facility. This diagnosis summarizes the patient's condition at the time of discharge and is used for follow-up care and management. "The determination of the nature of a disease or condition, or the distinguishing of one disease or condition from another. Assessment may be made through physical examination, laboratory tests, or the likes. Computerized programs may be used to enhance the decision-making process. (MSH) The process of identifying a disease, such as cancer, from its signs and symptoms. (NCI) Type of Diagnosis are: Provisional/ Final/ Admission/ Interim/ Working/ Discharge (EHRMDS) EHRMDS Diagnosis type opencare:DiagnosticImagingResult The result of an evaluation technique using a visual display of structural or functional patterns of organs or tissues that is performed to determine the presence, absence, or degree of a condition. (NCI) OpneEMR Diagnostic imaging result Imaging Radiology opencare:Dietitian Dietitians are health professionals who specialize in the science of nutrition and dietetics. They work with individuals or groups to help them improve their health through the use of proper nutrition and dietary choices. Dietitians often work in healthcare settings, such as hospitals, clinics, and long-term care facilities, but they may also work in private practice, community settings, or the food industry. They provide advice on food and nutrition to promote healthy eating habits and prevent or manage various health conditions such as obesity, diabetes, and heart disease. Dietitians also work with athletes and sports teams to optimize their nutrition for peak performance. They are trained to assess, diagnose, and treat nutrition-related problems and to develop personalized nutrition plans based on an individual's specific needs and goals. Dietitian opencare:Disease A definite pathologic process with a characteristic set of signs and symptoms. It may affect the whole body or any of its parts, and its etiology, pathology, and prognosis may be known or unknown. (MSH) Any abnormal condition of the body or mind that causes discomfort, dysfunction, or distress to the person affected or those in contact with the person. The term is often used broadly to include injuries, disabilities, syndromes, symptoms, deviant behaviors, and atypical variations of structure and function. (NCI) Conceptually broad term referring primarily to physical illness. Also used when particular disorders are not specified. Use a more specific term if possible. For general discussions of health impairment consider also the term HEALTH. (PSY) UMLS CUI: C0012634 Disease opencare:District A district is a geographical or administrative division of a larger region or territory, typically used for governmental or electoral purposes. In some countries, districts are used as a subdivision of provinces or states, while in others they are used to divide up a city or metropolitan area. Districts can vary in size and population, and may have their own local government or administrative structure. In addition to their administrative or political functions, districts may also be used for statistical or planning purposes, such as analyzing population density or designing transportation networks. (Source: Investopedia, https://www.investopedia.com/terms/d/district.asp) District opencare:DrugAllergy Drug allergy opencare:DrugIntolerance Drug intolerance or drug sensitivity refers to an inability to tolerate the adverse effects of a medication, generally at therapeutic or subtherapeutic doses. FreeHealth Drug intolerance opencare:Encounter A "Patient Encounter" describes an interaction between a Patient and a healthcare provider. Types of Encounter can be: Appointments, Inpatient Stay, Outpatient Visit, Patient's General Practitioner Visit, Telephone Consultation, Hospital Encounter, Appointment, Office Visit A "Patient Visit" is a term used in healthcare to describe an in-person encounter between a patient and a healthcare provider, typically at a medical office, clinic, or hospital. During a PatientVisit, the healthcare provider will typically conduct a physical examination, review the patient's medical history, and discuss any health concerns or symptoms that the patient may be experiencing. The goal of a PatientVisit is to evaluate the patient's health status, diagnose any medical conditions, and provide appropriate treatment and recommendations. Sources: "PatientVisit" is a commonly used term in healthcare and is recognized by healthcare providers and organizations. Example: A PatientVisit may take place at a medical office or clinic, where a patient is seen by a primary care physician or specialist for a routine check-up or to address specific health concerns. During the visit, the healthcare provider may take vital signs, such as blood pressure and heart rate, and conduct a physical exam, as well as review the patient's medical history and current medications. Based on the results of the exam and discussions with the patient, the healthcare provider may make a diagnosis and recommend a treatment plan, such as medication, lifestyle changes, or further testing. Encounter Pateint encounter Patient visit Visit opencare:EncounterType EHRMDS Encounter type opencare:Endocrinologist An endocrinologist is a medical doctor who specializes in diagnosing and treating conditions related to the endocrine system, which is responsible for producing hormones. This includes conditions such as diabetes, thyroid disorders, and hormonal imbalances. They also perform procedures such as thyroid biopsies. Source: https://www.hormone.org/what-is-endocrinology Endocrinologist opencare:EnvironmentalAllergy These are caused by allergens in the environment such as pollen, mold, dust mites, and pet dander. Environmental allergy opencare:EnvironmentalSensitivity Environmental sensitivity opencare:Eukaryote One of the three domains of life (the others being BACTERIA and ARCHAEA), also called Eukarya. These are organisms whose cells are enclosed in membranes and possess a nucleus. They comprise almost all multicellular and many unicellular organisms, and are traditionally divided into groups (sometimes called kingdoms) including ANIMALS; PLANTS; FUNGI; and various algae and other taxa that were previously part of the old kingdom Protista. (MSH) Organism or cells with a nucleus separated from the cytoplasm by a two membrance nuclear envelope and compartmentalization of function into distinct cytoplasmic organelles. (NCI) Eukaryote opencare:FamilyHistory Family history refers to a record of a person's family members and their medical conditions or health issues. This information may include details about a person's parents, siblings, grandparents, and other close relatives, as well as any medical conditions or illnesses they have experienced. A family history can provide valuable information about potential genetic or hereditary health risks, which may increase a person's likelihood of developing certain conditions or diseases. Healthcare providers often ask about a person's family history as part of a medical evaluation, particularly for conditions such as heart disease, cancer, diabetes, and certain genetic disorders. Individuals can help ensure that their healthcare providers have accurate and up-to-date information about their family history by gathering and documenting relevant information from family members and sharing it with their healthcare team. (Source: National Institutes of Health, https://ghr.nlm.nih.gov/primer/medicalhistory/familyhistory) EHRMDS Family history opencare:Finding That which is discovered by direct observation or measurement of an organism attribute or condition, including the clinical history of the patient. The history of the presence of a disease is a 'Finding' and is distinguished from the disease itself. Finding opencare:Food A group of materials of either plant, animal or artificial origin containing essential body nutrients that can be ingested by an organism to produce energy, stimulate growth, and maintain life. (NCI) A group of substances which are consumed by humans and animals. (NCI) Substances taken in by the body to provide nourishment. (MSH) Food opencare:FoodAllergy Primary food allergies primarily occur as a result (most likely) of gastrointestinal sensitization to predominantly stable food allergens (glycoproteins). A secondary food allergy develops after primary sensitization to airborne allergens (e. g., pollen allergens) with subsequent reactions (due to cross-reactivity) to structurally related often labile allergens in (plant) foods. Food allergy opencare:FoodSensitivity Food sensitivity opencare:Fungus A kingdom of eukaryotic, heterotrophic organisms that live as saprobes or parasites, including mushrooms, yeasts, smuts, molds, etc. They reproduce either sexually or asexually, and have life cycles that range from simple to complex. Filamentous fungi refer to those that grow as multicellular colonies (mushrooms and molds). (NCI) A kingdom of eukaryotic, heterotrophic organisms that live parasitically as saprobes, including MUSHROOMS; YEASTS; smuts, molds, etc. They reproduce either sexually or asexually, and have life cycles that range from simple to complex. Filamentous fungi, commonly known as molds, refer to those that grow as multicellular colonies. (MSH) A plant-like organism that does not make chlorophyll. Mushrooms, yeasts, and molds are examples. The plural is fungi. (NCI) Fungus opencare:Gastroenterologist A gastroenterologist is a medical doctor who specializes in diagnosing and treating conditions related to the digestive system. This includes conditions such as irritable bowel syndrome, Crohn's disease, and colon cancer. They also perform procedures such as colonoscopies and endoscopies. Source: https://www.gastro.org/practice-guidance/gi-patient-center/topic/gastroenterologist Gastroenterologist opencare:GenderType Type of Gender, whether male, female or Transgender Gender type opencare:GeneticFinding Diagnosis, consultation, and procedures intended to prevent, identify, or treat birth defects, congenital anomalies, or conditions. (OMS) GNUHealth Genetic finding Genetics opencare:GeneticTest Genetic testing is a medical test that examines a person's DNA to look for specific changes or mutations in genes, chromosomes, or proteins. It is used to identify the risk of developing certain genetic disorders, to diagnose genetic conditions, and to determine a person's likelihood of passing on a genetic disorder to their offspring. Source: National Human Genome Research Institute Genetic test opencare:GeographycalRegion Geographical Region means a geographical area with a contiguous boundary that may enclose a portion of any county or counties. Geographycal region GeographicRegion opencare:HealthRecord Health record of an individual patient Health record opencare:Hematologist A hematologist is a medical doctor who specializes in diagnosing and treating conditions related to blood, blood-forming organs, and the immune system. This includes conditions such as anemia, leukemia, and lymphoma. They also perform procedures such as bone marrow biopsies. Source: https://www.cancer.net/navigating-cancer-care/diagnosing-cancer/find-hematologist-oncologist Hematologist opencare:History History opencare:HospitalPharmacist A hospital pharmacist is a pharmacist who works in a hospital setting and is responsible for preparing and dispensing medications to patients in the hospital. They also work closely with healthcare providers to ensure that patients receive appropriate medication therapy. [Source: American Society of Health-System Pharmacists] Hospital pharmacist opencare:ImagingProcedure An imaging procedure is a medical test or exam that uses different techniques to create pictures of the inside of the body. It is used to diagnose or monitor the progress of a disease or medical condition, and to guide medical procedures. Source: RadiologyInfo, Radiological Society of North America Imaging procedure opencare:ImmunizationHistory Immunization history refers to a record of a person's vaccinations or immunizations received throughout their life. This information may include the type of vaccine, the date of administration, and any adverse reactions or side effects experienced. Immunization history is important for several reasons. First, it can help healthcare providers determine which vaccines a person may need based on their age, health status, and other factors. Second, it can help track the spread of vaccine-preventable diseases and identify areas where vaccination efforts may need to be increased. Finally, having an up-to-date immunization history can be required for certain activities such as travel or school attendance. . (Source: Centers for Disease Control and Prevention, https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/appendices/appdx-full-g.pdf) EHRMDS Immunization history opencare:ImplantHistory Implant history refers to a person's medical history related to the use of medical implants, such as artificial joints, pacemakers, or dental implants. This information may include the type of implant, the date of implantation, and any complications or adverse reactions experienced. Medical implants are commonly used to treat a variety of health conditions, from joint pain to heart disease to tooth loss. While implants can improve quality of life for many people, they can also carry risks, such as infection, implant failure, or allergic reactions. A person's implant history is important for several reasons. First, it can help healthcare providers determine which treatments or interventions may be appropriate based on a person's medical history and current health status. Second, it can help track the safety and effectiveness of different types of implants and identify areas where improvements may be needed. (Source: U.S. Food and Drug Administration, https://www.fda.gov/medical-devices/implants-and-prosthetics/implants-and-prosthetics) Implant history opencare:ImplantProcedure A surgical procedure that places something in the human body. (NCI) Introduction of a non biologic device (SNOMEDCT_US) SCTID 782902008 The act of fixing something firmly or setting something securely or deeply into the body. (SNOMEDCT_US) To put in between or into a part(s) of the body. (SNOMEDCT_US) SNOMED CT Implant procedure Implantation process opencare:Infection Contamination with disease-producing germs (CCC) Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. (MSH) The invasion of an organism's body tissues by disease-causing agents and their multiplication, as well as the reaction by the host to these organisms and/or toxins that the organisms produce. (NCI) UMLS CUI: C3714514 Infection opencare:InfectiousDiseaseSpecialist An infectious disease specialist is a medical doctor who specializes in diagnosing and treating conditions caused by infectious agents such as bacteria, viruses, fungi, and parasites. This includes conditions such as HIV/AIDS, tuberculosis, and hepatitis. They also provide guidance on preventing the spread of infectious diseases. Source: https://www.idsociety.org/patient-care/frequently-asked-questions-about-infectious-diseases/ Infectious disease specialist opencare:InsectStingAllergy These are caused by the venom of stinging insects such as bees, wasps, and hornets. Insect sting allergy opencare:LaboratoryFinding Results of fluid and tissue tests such as urine and blood analysis. (OMS) The outcome of a laboratory test. (NCI) Laboratory finding opencare:LaboratoryTest Laboratory testing refers to a wide range of medical tests, exams or procedures that are performed on samples of blood, urine, tissue, or other body fluids or substances to diagnose, monitor, or treat a disease or medical condition. Source: Lab Tests Online, American Association for Clinical Chemistry Laboratory test opencare:LatexAllergy Latex allergy opencare:LicensedPracticalNurse A licensed practical nurse (LPN) is a nurse who has completed a practical nursing program and passed a national licensing exam to obtain a nursing license. They are responsible for providing basic patient care, such as taking vital signs, administering medications, and assisting with activities of daily living. LPNs work under the supervision of RNs and other healthcare professionals. (Source: https://www.bls.gov/ooh/healthcare/licensed-practical-and-licensed-vocational-nurses.htm) Licensed practical nurse opencare:Man an individual human; especially : an adult male human." (Source: Merriam-Webster Dictionary, https://www.merriam-webster.com/dictionary/man) Man opencare:MedicalProceduresSensitivity Medical procedures sensitivity opencare:MedicalSpeciality According to the World Health Organization (WHO), a medical specialty is a "defined area of medical practice that is concerned with a particular function, organ, disease or age group and requires special training beyond the basic medical education." (Source: WHO, "WHO Handbook for Reporting Results of Cancer Treatment") This definition highlights that medical specialties require specialized knowledge and training beyond what is covered in basic medical education, and that they are focused on specific areas of medical practice. Examples of medical specialties include cardiology, dermatology, oncology, pediatrics, and psychiatry. MedicalSpeciality refers to a particular field or branch of medicine that focuses on the diagnosis, treatment, and prevention of specific medical conditions or diseases. It involves specialized knowledge, skills, and training beyond the basic medical education, and practitioners in a medical specialty typically have a narrower focus of practice than general practitioners. Medical specialties are defined by their particular function, organ, disease, or age group, and they are recognized and regulated by professional medical organizations and governing bodies. Examples of medical specialties include cardiology, dermatology, oncology, pediatrics, psychiatry, and many others. Medical speciality opencare:MedicalTherapy Medical therapy refers to the use of drugs, medications, or other non-surgical treatments to manage, cure, or prevent a disease or medical condition. Source: MedlinePlus, U.S. National Library of Medicine Medical therapy opencare:Medication A chemical or biologic substance, used as a medical therapy, that has a physiological effect on an organism. Here the term drug is used interchangeably with the term medicine although clinical knowledge make a clear difference between them. Medication Drug opencare:MedicationSensitivity Medication sensitivity opencare:MenstrualHistory A woman's menstrual history can provide important information about her reproductive health and can help healthcare providers identify any potential issues, such as irregular periods or painful menstruation, that may require further evaluation or treatment. (Source: American College of Obstetricians and Gynecologists, https://www.acog.org/womens-health/faqs/obstetric-history-and-examination) EHRMDS Menstrual history opencare:Neurologist A neurologist is a medical doctor who specializes in diagnosing and treating conditions related to the nervous system, including the brain, spinal cord, and nerves. This includes conditions such as epilepsy, multiple sclerosis, and Parkinson's disease. They also perform procedures such as electromyography and lumbar punctures. Source: https://www.aan.com/patients/neurologist Neurologist opencare:Neurosurgeon A medical doctor who specializes in the surgical treatment of the nervous system, including the brain, spinal cord, and peripheral nerves. They diagnose and treat a variety of conditions, including tumors, traumatic injuries, and degenerative diseases of the spine. (Source: American Association of Neurological Surgeons - https://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/What-is-a-Neurosurgeon) Neuro surgeon opencare:Nurse Nurses are licensed health care professionals who provide patient care, including administering medications, monitoring vital signs, and providing emotional support to patients and their families. They may work in hospitals, clinics, nursing homes, and other health care settings. (Source: American Nurses Association, https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/) Nurse opencare:NursePractitioner A licensed healthcare professional who provides primary and specialty care to patients. They assess, diagnose, and treat various health conditions, prescribe medications, and provide patient education. Nurse practitioners work independently or in collaboration with physicians. [Source: https://www.aanp.org/all-about-nps/what-is-an-np] Nurse practitioner opencare:ObservationalFinding The act of measuring, questioning, evaluating, or otherwise observing a patient or a specimen from a patient in healthcare; the act of making a clinical judgment. The result, answer, judgment, or knowledge gained from the act of observing a patient or a specimen from a patient in healthcare Observational finding FindingOfObservation opencare:OccupationalAllergy These are caused by exposure to certain substances in the workplace such as dust, chemicals, and animal dander. Occupational allergy opencare:OccupationalTherapist Occupational therapists are health care professionals who help people of all ages participate in activities they need or want to do through the therapeutic use of daily activities (occupations). They work with individuals who have physical, mental, developmental, or emotional disabilities. (Source: American Occupational Therapy Association, https://www.aota.org/About-Occupational-Therapy.aspx) Occupational therapist opencare:Oncologist An oncologist is a medical doctor who specializes in diagnosing and treating cancer. This includes conditions such as breast cancer, lung cancer, and leukemia. They also perform procedures such as chemotherapy and radiation therapy. Source: https://www.cancer.net/navigating-cancer-care/cancer-basics/what-oncologist Oncologist opencare:Ophthalmologist A medical doctor who specializes in the diagnosis and treatment of eye disorders, both medically and surgically. They are trained to provide a full spectrum of eye care, including prescribing glasses and contact lenses, performing surgery, and treating medical conditions affecting the eyes. Source: American Academy of Ophthalmology.(Source: American Optometric Association, https://www.aoa.org/about-the-aoa/what-is-a-doctor-of-optometry; American Academy of Ophthalmology, https://www.aao.org/eye-health/about-ophthalmologists) Ophthalmologist opencare:Organism A living entity. (NCI) A living thing, such as an animal, a plant, a bacterium, or a fungus. (NCI) Any individual living (or previously living) being. EXAMPLE(S): animal, human being (NCI) Tree section heading term for organisms. (CSP) Organism opencare:OrthopedicSurgeon A medical doctor who specializes in the surgical treatment of conditions affecting the musculoskeletal system, including bones, joints, ligaments, tendons, and muscles. They perform surgeries to treat a range of conditions such as fractures, arthritis, and sports injuries. (Source: American Academy of Orthopaedic Surgeons - https://orthoinfo.aaos.org/en/treatment/orthopaedic-surgery/) Orthopedic surgeon opencare:PastHistory Past history refers to a person's medical history, including any past illnesses, injuries, or medical conditions. This information is important for healthcare providers in order to provide appropriate care and treatment. A person's past history may include details such as the types of illnesses or injuries experienced, the dates and durations of these events, any treatments received, and any complications or long-term effects. This information is often gathered during a medical evaluation, and may also be obtained from medical records or other sources. It can help healthcare providers identify potential risk factors or underlying medical conditions, and inform treatment decisions or recommendations for preventative care. It is important for individuals to inform their healthcare providers of any relevant past medical history, including any past surgeries, hospitalizations, or chronic conditions. This can help ensure that they receive appropriate care and treatment and that their medical records are accurate and up-to-date. (Source: U.S. National Library of Medicine, https://medlineplus.gov/ency/article/001933.htm) EHRMDS Past history opencare:PathologicProcess A biologic function or a process having an abnormal or deleterious effect at the subcellular, cellular, multicellular, or organismal level. (NCI) Abnormal mechanisms and forms involved in the dysfunctions of tissues and organs. (CSP) The abnormal mechanisms and forms involved in the dysfunctions of tissues and organs. (MSH) UMLS CUI: C0030660 Pathologic process opencare:PathologyFinding A specialty concerned with the nature and cause of disease as expressed by changes in cellular or tissue structure and function caused by the disease process. (MSH) The medical science, and specialty practice, concerned with all aspects of disease, but with special reference to the essential nature, causes, and development of abnormal conditions, as well as the structural and functional changes that result from the disease processes. Informally used to mean the result of such an examination. (NCI) Pathology finding opencare:PediatricSurgeon A medical doctor who specializes in surgical procedures for infants, children, and adolescents. They treat a variety of congenital and acquired conditions such as birth defects, tumors, and traumatic injuries. (Source: Children's Hospital Los Angeles - https://www.chla.org/pediatric-surgery) Pediatric surgeon opencare:Pediatrician A medical doctor who specializes in the medical care of infants, children, and adolescents. They are trained to diagnose and treat a wide range of medical conditions that affect children, from minor illnesses to more serious conditions such as asthma, diabetes, and cancer. Source: American Academy of Pediatrics. Pediatrician opencare:PediatricsHistory Pediatric history refers to a child's medical history, including information about their health, growth, and development. This information is important for healthcare providers to assess a child's health and identify any potential issues or concerns. A child's pediatric history may include details such as their birth weight and gestational age, their developmental milestones (such as crawling, walking, and talking), their past illnesses or injuries, and any medical conditions or allergies. It may also include information about their family history of medical conditions or genetic disorders. Pediatric history is important for several reasons. First, it can help healthcare providers identify potential risk factors or underlying medical conditions that may require further evaluation or treatment. Second, it can help healthcare providers monitor a child's growth and development over time and ensure that they are meeting important milestones. Finally, it can help inform recommendations for preventative care, such as vaccinations or routine health screenings. It is important for parents or guardians to inform their child's healthcare provider of any relevant pediatric history, including any past medical conditions, surgeries, or hospitalizations. This can help ensure that their child receives appropriate care and treatment, and that their medical records are accurate and up-to-date. (Source: American Academy of Pediatrics, https://www.aap.org/en-us/professional-resources/practice-transformation/quality-improvement/Pages/Pediatric-History.aspx) GNUHealth Pediatrics history opencare:PersonalHistory Personal history refers to a person's individual experiences, choices, and circumstances that have shaped their life. It can include a wide range of information, such as a person's education, employment, relationships, hobbies, and interests, as well as any significant life events or challenges they have faced. Personal history can be important in a variety of settings, including healthcare, where it can help inform medical decision-making and treatment planning. For example, a person's personal history may include details about their lifestyle habits, such as diet, exercise, and smoking, which can impact their health and risk for certain medical conditions. It may also include information about past traumas, such as abuse or neglect, that can affect a person's mental health and well-being. In addition, personal history can be important in social and legal contexts. For example, it may be relevant in a job interview or a legal proceeding, where a person's past experiences and behaviors can help provide context for their current situation. It is important for individuals to be aware of their personal history and how it may impact their health and well-being. This can include reflecting on past experiences and behaviors, and seeking support or treatment when necessary. It is also important for healthcare providers and other professionals to be sensitive to the role of personal history in a person's life, and to use this information in a respectful and supportive manner. (Source: U.S. National Library of Medicine, https://medlineplus.gov/ency/article/001930.htm) EHRMDS Personal history opencare:PharmaceuticalPreparation A drug product that contains one or more active and/or inactive ingredients; it is intended to treat, prevent or alleviate the symptoms of disease. This term does not refer to the individual ingredients that make up the product. (NCI) A finished dosage form, for example, tablet, capsule, solution, etc., that contains an active drug ingredient generally, but not necessarily, in association with inactive ingredients. The term also includes a finished dosage form that does not contain an active ingredient but is intended to be used as a placebo. [21CFR210.3] (NCI) A legal drug that is used to prevent, treat, or relieve symptoms of a disease or abnormal condition. (NCI) Drugs intended for human or veterinary use, presented in their finished dosage form. Included here are materials used in the preparation and/or formulation of the finished dosage form. (MSH) Pharmaceutical preparation opencare:Pharmacist Pharmacists are licensed health care professionals who dispense prescription medications to patients and provide advice on their proper use. They also advise physicians on drug interactions and monitor patients for adverse effects. (Source: American Pharmacists Association, https://www.pharmacist.com/what-pharmacist) Pharmacist opencare:PhysicalExamination an examination of the bodily functions and condition of an individual 75Health Physical examination opencare:PhysicalTherapist Physical therapists are licensed health care professionals who help patients manage pain and improve mobility after an injury or illness. They use a variety of techniques, including exercise and manual therapy, to help patients regain strength and movement. (Source: American Physical Therapy Association, https://www.apta.org/AboutPTs/) Physical therapist opencare:Physician Medical doctors are licensed health care professionals who diagnose, treat, and prevent illnesses and injuries. They also provide advice on maintaining good health. (Source: American Medical Association, https://www.ama-assn.org/life-career/physician-career-planning/what-physician) Physician Doctor Medical doctor opencare:Plant Any living organism that typically synthesizes its food from inorganic substances, possesses cellulose cell walls, responds slowly and often permanently to a stimulus, lacks specialized sense organs and nervous system, and has no powers of locomotion. (EPA Terminology Reference System) (NCI) Any of various photosynthetic, eukaryotic, multicellular organisms of the kingdom Plantae characteristically producing embryos, containing chloroplasts, having cellulose cell walls, and lacking the power of locomotion, such as trees, flowers, shrubs and vines. (ICF) Any of various photosynthetic, eukaryotic, multicellular organisms of the kingdom Plantae characteristically producing embryos, containing chloroplasts, having cellulose cell walls, and lacking the power of locomotion, such as trees, flowers, shrubs and vines. (ICF-CY) Plant opencare:PlantSubstance material derived from plants. Plant substance opencare:PlasticSurgeon A medical doctor who specializes in the surgical and non-surgical treatment of conditions affecting the skin, soft tissues, and underlying structures of the body. They perform cosmetic and reconstructive procedures to treat a variety of conditions such as burns, birth defects, and cancer. (Source: American Society of Plastic Surgeons - https://www.plasticsurgery.org/cosmetic-procedures) Plastic surgeon opencare:PresentHistory The term "present history" refers to the current or most recent medical concerns or symptoms that a patient is experiencing at the time of a medical evaluation. Present history refers to a patient's current or most recent medical concerns or symptoms. Example: During a medical evaluation, a patient reports experiencing shortness of breath, chest pain, and coughing. These symptoms would be considered part of the patient's present history, as they are the medical concerns that are most relevant to the current evaluation. EHRMDS Present history opencare:Prokaryote Cells lacking a nuclear membrane so that the nuclear material is either scattered in the cytoplasm or collected in a nucleoid region. (MSH) Cells such as those of bacteria and the blue green algae which lack a true nucleus or nuclear membrane so that the nuclear material is either scattered in the cytoplasm or collected in a nucleoid region. (CSP) Organisms without a cell nucleus or any other membrane-bound organelles. Most prokaryotes are bacteria but the group includes both the Bacteria and the Archaea. Eukaryota, Bacteria, and Archaea are now considered the top nodes of a three-domain taxonomy system. (NCI) Prokaryote opencare:Psychiatrist Psychiatrists are medical doctors who specialize in diagnosing, treating, and preventing mental illness, including substance abuse disorders. They use a range of treatments, including medications and psychotherapy. (Source: American Psychiatric Association, https://www.psychiatry.org/patients-families/what-is-psychiatry) Psychiatrist opencare:RadiationTherapy Radiation therapy is a medical treatment that uses high-energy radiation, such as X-rays, gamma rays, or charged particles, to kill or shrink cancerous cells or tumors. It is used to treat various types of cancer and some noncancerous conditions. Source: American Cancer Society Radiation therapy opencare:RadiologicTechnologist Radiologic technologists are health care professionals who operate medical imaging equipment, such as X-ray machines and CT scanners, to create images of a patient's internal structures. They work with radiologists and other physicians to diagnose and treat medical conditions. (Source: American Society of Radiologic Technologists, https://www.asrt.org/main/about-asrt/radiologic-technology) Radiologic technologist opencare:Radiologist A medical doctor who specializes in using medical imaging techniques, such as X-rays, CT scans, and MRI scans, to diagnose and treat diseases and injuries. They work closely with other physicians to provide accurate and timely diagnoses and treatment plans. Source: American College of Radiology. Radiologist opencare:RecreationalDrug "A drug used for personal enjoyment rather than for medicinal purposes. (NCI) " GNUHealth Recreational drug opencare:Region A position, site, or point in space where something can be found. (NCI) A spatial region or named place. (NCI) Region Location opencare:RegisteredNurse A registered nurse (RN) is a nurse who has completed a nursing program and passed a national licensing exam to obtain a nursing license. They are responsible for providing patient care, administering medications, and coordinating care with other healthcare professionals. RNs may specialize in a particular area of nursing, such as pediatrics, oncology, or emergency care. (Source: https://www.bls.gov/ooh/healthcare/registered-nurses.htm) Registered nurse opencare:RespiratoryTherapist A respiratory therapist is a healthcare professional who specializes in the assessment, treatment, and care of patients with respiratory disorders, such as asthma, chronic obstructive pulmonary disease (COPD), and emphysema. They work with physicians and other healthcare professionals to develop and implement treatment plans for patients with respiratory conditions. Respiratory therapists also perform diagnostic tests, such as pulmonary function tests, to evaluate a patient's lung function and monitor their response to treatment. Additionally, they may provide patient education and support to help individuals manage their respiratory conditions and improve their overall quality of life. Respiratory therapist opencare:RetailPharmacist A retail pharmacist is a pharmacist who works in a retail setting, such as a drugstore or grocery store, and dispenses medications to patients. They also provide counseling to patients on the appropriate use of medications and potential side effects. [Source: Pharmacy Times] Retail pharmacist opencare:ReviewOfSystem A comprehensive assessment of a patient, which includes a subjective history taking component as well as an objective based structured interview and physical examination of all the body systems. (NCI) A series of questions concerning each organ system and region of the body, asked of the patient during history taking and physical examination in order to gain an optimal understanding of the patient's presenting illness and medical history. Solismed Review of system opencare:Rheumatologist A rheumatologist is a medical doctor who specializes in diagnosing and treating rheumatic diseases, which are conditions that affect the joints, bones, muscles, and sometimes other internal organs. These conditions include arthritis, lupus, fibromyalgia, and other connective tissue diseases. Source: American College of Rheumatology. "What is a Rheumatologist?" https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Health-Care-Team/What-is-a-Rheumatologist Rheumatologist opencare:RiskFactor An aspect of personal behavior or lifestyle, environmental exposure, inborn or inherited characteristic, which, based on epidemiological evidence, is known to be associated with a health-related condition considered important to prevent. (MSH) Any aspect of an individual's life, behavior, an environmental exposure, or an inborn or inherited characteristic that increases the likelihood of a disease, condition or injury. (NCI) FreeHealth Risk factor opencare:RouteBySite "Route of substance administration classified by site. (HL7V3.0) " Route by site opencare:SeasonalAllergy These are caused by the allergens that are present during certain seasons such as pollen during the spring and fall. Seasonal allergy opencare:Sensitivity the quality or state of being sensitive Sensitivity opencare:Severity The degree of something undesirable. (NCI) Used of the degree of something undesirable e.g. pain or weather; also, strictness. (NCI) OpenMRS Severity opencare:SiteOfCare A place/organization where medical treatment is occurred/is performed. eg. Health encounter sites, Health maintenance organization, Hospital AND/OR institution, Hospital-based outpatient allergy clinic, Hospital-based outpatient department, Hospital-based outpatient immunology clinic, Land ambulance, Mass casualty setting, Military health institution, Nursing home AND/OR ambulatory care site etc. Site of care opencare:SkinAllergy These are caused by contact with certain substances such as cosmetics, soaps, and metals like nickel. Skin allergy opencare:SocialHistory Social history refers to a person's cultural, economic, and environmental circumstances that can influence their health and well-being. It includes information about a person's upbringing, education, occupation, living conditions, and social relationships, as well as their beliefs, values, and cultural practices. Social history is important in healthcare because it can provide insight into a person's risk for certain medical conditions, as well as their ability to access healthcare services and follow treatment plans. For example, a person's social history may reveal that they have limited access to healthy food options or safe living conditions, which can increase their risk for chronic diseases like obesity or asthma. It may also reveal that they face discrimination or other social barriers that can impact their mental health and well-being. In addition, social history can be used to inform healthcare interventions and policies that address the social determinants of health, such as poverty, housing insecurity, and racial and ethnic disparities. This can include efforts to improve access to healthy food options, affordable housing, and quality education, as well as efforts to reduce discrimination and other social barriers to health. It is important for healthcare providers to gather and use social history information in a culturally sensitive and respectful manner, recognizing that social factors can have a profound impact on a person's health and well-being. (Source: U.S. National Library of Medicine, https://medlineplus.gov/ency/article/001929.htm) Solismed Social history opencare:SocialWorker A healthcare professional who specializes in the assessment and management of patients' social and emotional needs. They provide counseling, support, and assistance with accessing community resources. They provide care in a variety of settings, including hospitals, clinics, and social service agencies. (Source: National Association of Social Workers) Social worker opencare:SpeechTherapist Speech and language therapists (also known as speech-language pathologists) are health care professionals who work with people who have communication or swallowing disorders. They help patients improve their ability to communicate, speak, and swallow. (Source: American Speech-Language-Hearing Association, https://www.asha.org/public/) Speech therapist opencare:Status Designation of a concept's state. Normally is not populated unless the state is retired.. (HL7V3.0) Status opencare:Supplement Something added to complete a thing, make up for a deficiency, or extend or strengthen the whole; serving to complete or make an addition. (NCI) NoshEMR Supplement opencare:Surgeon Surgeons are physicians who specialize in performing operations to treat injuries, diseases, and deformities. They use a variety of surgical techniques, including minimally invasive surgery, to operate on patients. (Source: American College of Surgeons, https://www.facs.org/education/patient-education/patient-resources/surgeons) Surgeon opencare:Surgery Intentional, structural alteration of the human body by mechanical, thermal, light-based, electromagnetic, or chemical means, and/or by the incision or destruction of tissues using instruments to cut, burn, vaporise, freeze, suture, probe, or manipulate by closed reductions. (SNOMEDCT_US) Intentional, structural alteration of the human body by mechanical, thermal, light-based, electromagnetic, or chemical means, and/or by the incision or destruction of tissues using instruments to cut, burn, vaporize, freeze, suture, probe, or manipulate by closed reductions. (SNOMEDCT_US) Operations carried out for the correction of deformities and defects, repair of injuries, and diagnosis and cure of certain diseases. (Taber, 18th ed.). (MSH) Planned structural alteration of the body, usually requiring disruption of a body surface (usually skin or mucosa) (SNOMEDCT_US) OpenEMR Surgery opencare:SurgicalHistory Definition: Surgical history refers to a record of a patient's previous surgical procedures, including the type of surgery, date, and any complications or outcomes. Source: The definition of surgical history is widely used and recognized in the medical community. Example: If a patient has had their appendix removed in the past, they would have a surgical history that includes information about the date of the surgery, the type of procedure performed, and any complications or outcomes. Similarly, if a patient has had a previous knee surgery, their surgical history would include details about the type of surgery performed (e.g., arthroscopic surgery, joint replacement), the date of the surgery, and any complications or outcomes. Surgical history is an important component of a patient's overall medical history, as it can provide valuable information to healthcare providers when planning future treatments or procedures. NoshEMR Surgical history opencare:Symptom An indication that a person has a condition or disease. Some examples of symptoms are headache, fever, fatigue, nausea, vomiting, and pain. (NCI) Subjective evidence of disease perceived by the patient. (NCI) Symptom opencare:Town A town is a human settlement that is generally smaller than a city, but larger than a village. Towns typically have a higher population density than rural areas, and may have a variety of public services and amenities such as schools, hospitals, and shopping centers. The specific characteristics of a town can vary depending on the country and region, but in general, they are urban areas that serve as centers of commerce, culture, and administration for their surrounding rural areas. Towns may have their own local government, which is responsible for managing municipal services such as waste management, water supply, and road maintenance. (Source: Britannica, https://www.britannica.com/topic/town-urban-area) Town opencare:TraumaSurgeon A medical doctor who specializes in the surgical treatment of traumatic injuries, including those resulting from accidents, falls, and violent events. They work in emergency departments and trauma centers, and may also provide care for critically ill patients. (Source: American College of Surgeons - https://www.facs.org/education/patient-education/patient-resources/trauma) Trauma surgeon opencare:TreatmentProcedure Extent of understanding conveyed about a procedure required as part of a treatment regimen (NOC) Technical activities such as wound care, specimen collection, resistive exercises, and medication prescriptions that are designed to prevent, decrease, or alleviate signs and symptoms for the individual, family, or community. (OMS) EHRMDS Treatment procedure TreatmentAndProcedure opencare:VascularSurgeon Vascular surgeon A vascular surgeon is a medical doctor who specializes in the diagnosis and treatment of conditions affecting the circulatory system, including the arteries and veins. They are trained to perform surgical and non-surgical interventions to treat conditions such as aneurysms, varicose veins, and blockages in the arteries. Source: Society for Vascular Surgery. "What is a Vascular Surgeon?" https://vascular.org/patient-resources/vascular-treatments/what-vascular-surgeon opencare:Virus In medicine, a very simple microorganism that infects cells and may cause disease. Because viruses can multiply only inside infected cells, they are not considered to be alive. (NCI) Minute infectious agents whose genomes are composed of DNA or RNA, but not both. They are characterized by a lack of independent metabolism and the inability to replicate outside living host cells. (MSH) Virus opencare:Woman A woman is an adult human female. The term "woman" is typically used to distinguish adult females from girls or females who are minors. The term may also be used to refer to gender identity and expression, as some people identify as women regardless of their biological sex. Women have historically faced various forms of discrimination and inequality, and there are ongoing efforts to address these issues and promote gender equality. Woman 38.6 37.8 Cho Ray Hospital bilateral crackles in lung Respiratory examination Dr. John Doe Swelling 2020-01-22T00:00:00 0 2019-11-01T00:00:00 0 2022-02-01T00:00:00 2022-02-01T00:00:00 closely monitored for respiratory distress and as per the observation weaned off supplemental oxygen. 2022-02-10T00:00:00 true advised to continue practicing social distancing, wearing a mask, and practicing good hand hygiene to prevent the spread of the virus. advised to continue self-quarantine for an additional 14 days after discharge to prevent the spread of the virus 10 Cho Ray Hospital Centro Hospitalar Universitário do Porto XYZ Hospital Stent true 7.58 401 true chest X-ray shows diffuse bilateral infiltrates consistent with viral pneumonia. RTPCR test Chest X-ray Cardiology Dermatology Penicillin NSAIDS 65 2 33 208 59 61 38 35 Jane Smith 50 John Smith Heart Examination heart sounds were regular SkinRash Redness 2022-12-13T00:00:00 2023-02-14T00:00:00 Dyspnea 70.0 98 37.8 90 80 100 30 120 Open healthCare Ontology (OpenCare) is an integrated metadata vocabulary expressed as an ontological data model, to facilitate the effective reasoning of patient-specific electronic health record (EHR) data. The OpenCare model identifies the concepts and semantic types in the EHR data with the aim of enabling the representation of clinical data in a way that is accessible and usable by researchers and healthcare facility users. The development of OpenCare and its components is formalized using the Ontology Web Language (OWL). This framework aims to enhance the accessibility and user-friendliness of EHR clinical data. OCO: Open healthCare Ontology Opencare 2023-05-24 Bain, Debanjali Dutta, Biswanath https://creativecommons.org/licenses/by/4.0/ OCO https://w3id.org/opencare https://w3id.org/opencare CQ 1: What is the patient's medical history for a specific condition? CQ 2: What medications has the patient been prescribed, and for what duration? CQ 3: What are the vital signs and measurements of the patient over a certain period? CQ 4: What is the patient's current diagnosis, and what tests were performed to determine it? CQ 5: Retrieve all patients who have been diagnosed with certain diseases (e.g., COVID-19, diabetes mellitus, etc.) and are over the age of 40. CQ 6: Retrieve the surgery name and date of all patients who underwent a surgical procedure within the past 6 months. CQ 7: What are the allergies and adverse reactions of the patient to specific drugs? CQ 8: What is the patient's family medical history, and how does it affect their current condition? CQ 9: What are the current and past treatments that the patient has received for a specific condition? CQ 10: What is the patient's current clinical status, and what are the prognoses for their condition?