ISO 1828:2012 pdf download – Health informatics – Categorial structure for terminological systems of surgical procedures
4.2 Goal of the terminological system for which the categorial structure is set
The goal of each terminological system for surgical procedures shall be defned by the users and make statement on situations and applications for which the categorial structure is intended and the limits of use. EXAMPLE Controlled vocabulary, production for clinicians or comparison with another terminological system for coding centres. To be conformant with this International Standard, each terminological system for surgical procedures shall state its goal. To be conformant with EN 12264, each terminological system of health care and biomedical science shall also state that it is conformant to the categorial structure standard EN 12264 outside the limits of use in the subject feld of surgical procedures.
5 Domain constraint requirements
The list of minimal domain constraints required by the goal of the categorial structure shall contain among the different authorized representations of relations (3.9) and the different related authorized categories (3.8) the ones which are valid and necessary for the precise goal (4.2) of a categorial structure (3.1) for a terminological system of surgical procedures.
5.3 The surgical procedure terminological phrase shall include the category lesion (3.8.3) when the surgical deed is applied to a modifed human anatomy structure without mention of the disease that is the cause of the lesion. EXAMPLE 1 In the terminological phrase “puncture of a cyst of the kidney”, “cyst” is necessary for the puncture to be applied to the cyst which hasSite “kidney” and not to the kidney. EXAMPLE 2 In the terminological phrase “Removing a kidney for cancer”, “cancer” as a disease causing a tumour in the kidney is not necessary but the removed kidney modifed by a tumour shall be represented as “removing” hasObject “tumour” which hasSite “kidney”. NOTE Pathological conditions that do not affect the description of the surgical procedure shall be recorded elsewhere within the health care record using a terminological system for diagnosis statements.
5.4 Each surgical procedure terminological phrase may need more than one surgical deed (3.8.1 ). One surgical deed shall be chosen as a main deed and the others as subprocess deeds related to the main deed by the semantic link hasSubsurgicaldeed (3.9.4). EXAMPLE In the terminological phrase “straightening penis by plicating and excising of the corpus cavernosum”, the main surgical deed is “straightening” which hasSubsurgicaldeed “plicating of the corpus cavernosum” and “excising of the corpus cavernosum”.
5.5 The subprocess terminological phrase of each surgical procedure shall, as a minimum, consist of a surgical deed (3.8.1), the semantic link hasObject (3.9.1) and the category human anatomy (3.8.2) in relation to the semantic links hasObject (3.9.1 ) or hasSite (3.9.2) when the object does not belong to the category human anatomy but to the category lesion (3.8.3) or to the category interventional equipment (3.8.4). EXAMPLE 1 In the terminological phrase “endarteriectomy of the carotid bifurcation by everting”, the main surgical deed is “removing” which hasObject the endarterium of carotid bifurcation which is part of the category human anatomy and hasSubsurgical procedure “everting the carotid bifurcation”. The subprocess therefore has a surgical deed “everting”, related by the semantic link “has object” to “carotid bifurcation” which is part of the category human anatomy. EXAMPLE 2 In the terminological phrase “straightening penis by installing a prosthesis in the penis”, the main surgical deed is “straightening” which hasObject “penis” which is part of the category human anatomy and hasSubsurgicaldeed “installing a prosthesis in the penis”. The subprocess phrase therefore has a surgical deed “installing”, which hasObject “prosthesis” which is part of the category interventional equipment which hasSite “penis” which is part of the category human anatomy.