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Table 4 Examples of assertion categories of problem concepts in patient records.

From: A context-blocks model for identifying clinical relationships in patient records

Example Sentence Problem Assertion
On admission , the patient was found to have a mild fever, myalgias, and arthralgias that were relieved by Tylenol. “a mild fever”
“myalgias”
“arthralgias”
Present
Present
Present
Pending labs included wound , bacterial , and fungal cultures and serologies for Bartonella, Francisella, Yersinia, EBV, “Bartonella”
“Francisella”
“Yersinia”
“EBV”
Possible
Possible
Possible
Possible
It would be useful to follow this at outpatient if the patient is symptomatic . “symptomatic” Hypothetical
He denied ever having any chest pain , chest pressure , shortness of breath , dyspnea on exertion and he was discharged to home . “chest pain”
“chest pressure”
“shortness of breath”
“dyspnea”
Absent
Absent
Absent
Conditional
Patient has a family history of coronary artery disease “coronary artery disease” Associated with someone else