Healthcare & Clinical Terms
Reference guide for medical and clinical terminology used in healthcare AI evaluation.Triage & Urgency
The process of determining the priority of patients’ treatments based on the severity of their condition. In healthcare AI, triage systems classify patient urgency to route them to appropriate care pathways.
The level of severity of a patient’s illness or condition. Higher acuity indicates more severe or complex cases requiring immediate attention.
A five-level triage algorithm used in emergency departments:
- ESI-1: Immediate life-saving intervention required
- ESI-2: High risk, confused, lethargic, or severe pain
- ESI-3: Multiple resources needed but stable
- ESI-4: One resource needed
- ESI-5: No resources needed
When a patient is assigned a lower urgency level than their condition warrants. This is a critical safety concern as it may delay necessary care.
When a patient is assigned a higher urgency level than necessary. While safer than under-triage, it can strain healthcare resources.
A symptom or sign that indicates a potentially serious underlying condition requiring immediate attention. Examples include chest pain with radiation, sudden severe headache, or signs of stroke.
Providing patients with clear instructions about warning signs that should prompt them to seek immediate care, even after initial assessment suggests lower acuity.
Clinical Documentation
A structured documentation format:
- Subjective: Patient’s reported symptoms and history
- Objective: Measurable findings (vitals, exam, labs)
- Assessment: Clinical diagnosis or impression
- Plan: Treatment, follow-up, referrals
A chronological description of the patient’s current complaint, including onset, location, duration, character, aggravating/alleviating factors, radiation, and timing (OLDCARTS).
The primary symptom or concern that prompted the patient to seek medical attention, typically documented in the patient’s own words.
A systematic inventory of body systems to identify symptoms the patient may not have mentioned. Includes constitutional, cardiovascular, respiratory, GI, neurological, and other systems.
Documentation of patient’s previous medical conditions, surgeries, hospitalizations, and chronic diseases.
A list of possible conditions that could explain a patient’s symptoms, ranked by likelihood. AI systems should consider appropriate differentials when evaluating triage decisions.
Symptoms & Conditions
Difficulty breathing or shortness of breath. A red flag symptom that may indicate cardiac, pulmonary, or other serious conditions.
Temporary loss of consciousness due to reduced blood flow to the brain. Requires evaluation for cardiac arrhythmias or other serious causes.
Excessive sweating, often associated with cardiac events, hypoglycemia, or shock. Important red flag when combined with chest pain.
Pain that spreads from its origin to other body areas. Classic example: chest pain radiating to left arm or jaw suggests cardiac origin.
Early symptoms indicating the onset of a disease before more specific symptoms appear. Important for identifying conditions like migraines or seizures.
The presence of one or more additional conditions co-occurring with a primary condition. Affects triage decisions and treatment planning.
Medical Imaging
Digital Imaging and Communications in Medicine. The international standard for medical images and related information, defining formats for storing and transmitting medical imaging data.
The type of medical imaging equipment or technique used:
- CR/DR: Computed/Digital Radiography (X-ray)
- CT: Computed Tomography
- MRI: Magnetic Resonance Imaging
- US: Ultrasound
- PET: Positron Emission Tomography
Picture Archiving and Communication System. A medical imaging technology for storing, retrieving, and distributing medical images electronically.
The written interpretation of medical images by a radiologist, including findings, impressions, and recommendations.
Software that assists radiologists by highlighting suspicious areas in medical images for further review.
An observation noted in medical imaging, such as a nodule, opacity, or anatomical variation. Can be normal, incidental, or clinically significant.
Healthcare Standards
International Classification of Diseases, 10th Revision. A medical coding system for diagnoses, symptoms, and procedures. Used for billing, epidemiology, and clinical documentation.
A coding system for medical procedures and services, maintained by the American Medical Association.
Systematized Nomenclature of Medicine - Clinical Terms. A comprehensive clinical terminology system used for clinical documentation and health information exchange.
Logical Observation Identifiers Names and Codes. A universal standard for identifying medical laboratory observations and clinical measurements.
A normalized naming system for generic and branded drugs, enabling interoperability between pharmacy systems and EHRs.
Care Settings
Hospital department providing immediate care for acute illnesses and injuries. Also called Emergency Room (ER).
Facilities providing immediate care for non-life-threatening conditions, typically with shorter wait times than EDs.
First-contact healthcare provided by physicians, nurse practitioners, or physician assistants for routine and preventive care.
Healthcare services delivered remotely via telecommunications technology, including video visits, phone consultations, and remote monitoring.
The outcome or next steps for a patient after evaluation, such as admission, discharge, transfer, or referral.
Clinical Protocols
Evidence-based recommendations for diagnosis and treatment of specific conditions, developed by medical organizations and expert panels.
A standardized set of steps or procedures to follow for specific clinical situations, ensuring consistent and safe care.
Pre-defined groups of orders (labs, medications, imaging) for specific conditions or procedures, embedded in EHR systems.
A multidisciplinary care plan outlining the essential steps in caring for patients with a specific clinical problem.
Automated notifications in EHR systems that alert clinicians to important clinical information or recommended actions.