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 |