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Patient vs Subject

The |Situation with explicit context (situation)| hierarchy is intended for concepts that explicitly include contextual information.  Context can include whom the finding is about, or on whom a procedure is performed.  These concepts can be used to represent different meanings, e.g., past history, family history, planned care, excluded diagnosis, etc.

In contrast, a concept in the Clinical Finding or Procedure hierarchy has a default Intended Use of the subject of the record. This context can be overridden by the information model.

For example,

• • The concept |Asthma (disorder)| could be used in a family history field to represent a family history of asthma.

However, including the term subject or patient within a Clinical finding or Procedure concept prevents that concept’s context from being overridden by the information model.

For example,

• • The concept |Patient immunocompromised (finding)| could not be used in a family history field to represent that a family member is immunocompromised.

Therefore, the use of patient and subject should be used only when necessary. 

Descriptions should use the word word subject, not not patient, if required. Subject , as subject is broader than patient.

For example, 

Conceptt420058008 |Provider
• 420058008 | Provider of history other than subject (person)|

Subject refers to the subject of record, who may, in some circumstances, not be the patient.

Best practice is to create a contextless concept.

Example - finding,

• • Patient unable to chew with denture (finding) - incorrect
  • Unable to chew with denture (finding) - correct

Example - procedure,

• • Positioning subject in supine position (procedure) -incorrect
  • Positioning in supine position (procedure) - correct

Caregiver vs Carer

Descriptions with caregiver should be as follows:

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