Clinical Text Item
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A Clinical Text Item is a domain-specific text item from a clinical domain.
- Context:
- It can (typically) reference Clinical Terms.
- It can (often) contain Medical Information about a patient's health condition, medical history, or treatments received.
- It can be generated by a Healthcare Professionals.
- It can be generated during patient visits, or as a part of medical investigations and procedures.
- It can be an input to a Clinical Text Processing System, such as a: Healthcare Natural Language API.
- It can be coded in specific medical terminologies like SNOMED CT, LOINC, ICD-10, or others.
- It can be included in different types of clinical documents such as discharge summary, medical report, clinical note, prescription, etc.
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- Example(s):
- A Doctor's Note, such as in a patient's medical record describing symptoms, diagnosis, and treatment.
- A Radiology Report, such as one that details the findings of an MRI scan.
- A Patient Progress Note, such as in an inpatient setting.
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- Counter-Example(s):
- A Structure Clinical Record, such as:
- aClinical Lab Result, represented in structured format.
- a Patient Demographic Record, such as in a healthcare database.
- A Legal Text Item.
- A Structure Clinical Record, such as:
- See: Clinical Documentation, Clinical Text Mining, Electronic Health Records, Healthcare Natural Language API, Clinical Text Dataset, Clinical Data Record, Radiology Report.