The purpose of this Technical Specification is to specify a categorial structure, within the subject field of
patient findings and problems, by defining a set of common domain constraints for use within terminological
systems including a classification, coding scheme, coding system, reference terminology and clinical
terminology.
Clinical findings are concepts that are recorded in clinical records and can describe any state observed
directly or indirectly concerning a patient and their relationship with the environment. This Technical
Specification is focused on a sub-population of these findings concerning in vivo descriptions of state
(structure and function) directly related to the patient. This class of concepts includes:
? diseases, which may be defined as a state caused by a known or assumed pathological process
impairing the normal physiological function and/or anatomical structure affecting all or part of a patient,
where a specific pathological change is caused by a defined mechanism;
? findings of state or function (including normal findings) observed directly relating to a patient.