DiagnosisEvidence

Clinical evidence that supports or confirms a diagnosis, linking observations, laboratory results, imaging findings, and clinical assessments. Documents the evidentiary chain supporting diagnosis validation with both structured data references and narrative descriptions.

Overview

DiagnosisEvidence connects a diagnosis to the clinical data that supports it. This includes lab results, imaging findings, physical exam observations, and clinical assessments. Evidence can be linked as structured references (to ClinicalObservation) or documented as narrative text. This entity supports clinical reasoning documentation, quality assurance, and the evidentiary chain for diagnostic conclusions.

Key Concepts

Evidence Types

Evidence can take multiple forms:

Type	Field	Description
Observation	`observation`	Structured clinical observation
Laboratory	`labResult`	Lab test results (text)
Imaging	`imagingStudy`	Radiology findings (text)
Narrative	`detail`	Free-text description

Evidence Coding

The code field classifies evidence type using Coding:

SNOMED-CT for evidence categories
Laboratory test (15220000)
Imaging (363679005)
Physical examination (5880005)
Evaluation procedure (386053000)

Structured Evidence

The observation field links to ClinicalObservation:

Vital signs supporting diagnosis
Exam findings
Lab values
Quantitative measurements

Narrative Evidence

Free-text fields capture unstructured evidence:

detail - Clinical reasoning and interpretation
labResult - Lab findings (pending full LIS integration)
imagingStudy - Imaging results (pending PACS integration)

Documentation

Attribution fields track who documented evidence:

recordedDate - When evidence was documented
recordedBy - Practitioner who documented

Use Cases

Documenting Lab Evidence

When lab supports diagnosis:

Create DiagnosisEvidence linked to diagnosis
Code as laboratory test (SNOMED-CT)
Reference structured observation if available
Document lab result text
Provide interpretive detail
Record documenter and date

Documenting Imaging Evidence

When imaging confirms diagnosis:

Create DiagnosisEvidence for diagnosis
Code as imaging (SNOMED-CT)
Document imaging study reference
Describe radiologic findings in detail
Link to radiology report

Physical Exam Findings

When exam supports diagnosis:

Create DiagnosisEvidence
Code as physical examination
Link to ClinicalObservation for exam finding
Describe examination findings
Document clinical significance

Building Diagnostic Chain

For comprehensive documentation:

Create evidence for each supporting finding
Link all to the same diagnosis
Document temporal sequence (recordedDate)
Provide synthesis in detail field
Calculate evidenceCount for completeness

Quality Assurance

For diagnostic review:

Query all evidence for a diagnosis
Check hasStructuredEvidence flag
Review evidence count
Verify appropriate documentation
Ensure diagnostic support is adequate

Related Entities

Entity	Relationship	Description
Diagnosis	Belongs to	Diagnosis being supported
Coding	Contains	Evidence type code
ClinicalObservation	References	Structured clinical observation
Practitioner	References	Who documented the evidence

Calculated Fields

Field	Type	Description
`hasStructuredEvidence`	boolean	True when observation, labResult, or imagingStudy is present
`evidenceCount`	number	Count of non-null evidence references

10 properties

Schema

Properties

Property	Type	Mode	Description	Required
diagnosis	Diagnosis	stored	Reference to the clinical diagnosis that this evidence supports or confirms - establishes the direct linkage between diagnostic conclusion and supporting clinical data Example: `"encounter-dx-001"`	Required
code	Coding	stored	Standardized code classifying the type of evidence using SNOMED-CT, LOINC, or other medical terminology systems - enables semantic categorization and retrieval of evidence by type across diagnostic workflows Example: `{"code":"386053000","system":"SNOMED-CT","display":"Evaluation procedure"}`	Optional
detail	string	stored	Free-text narrative description of the evidence, clinical reasoning, interpretation, or contextual information that supports the diagnosis but cannot be fully captured in structured fields Example: `"Chest X-ray reveals bilateral infiltrates consistent with pneumonia, correlating with elevated white blood cell count and clinical presentation of fever and productive cough"`	Optional
observation	ClinicalObservation	stored	Reference to a structured clinical observation that provides supporting evidence for the diagnosis - links quantitative measurements, qualitative assessments, or coded findings that substantiate the diagnostic conclusion Example: `"observation-12345"`	Optional
labResult	string	stored	Free-text reference to laboratory test results supporting the diagnosis - temporary string field pending full laboratory information system integration, will evolve to structured reference type Example: `"Lab order #LAB-2024-03456: Complete Blood Count showing WBC 18,500/μL (elevated), consistent with bacterial infection"`	Optional
imagingStudy	string	stored	Free-text reference to imaging study findings supporting the diagnosis - temporary string field pending full PACS/radiology integration, will evolve to structured ImagingStudy reference type Example: `"Radiology Study #RAD-2024-07890: CT Chest with contrast - Right lower lobe consolidation with air bronchograms, consistent with community-acquired pneumonia"`	Optional
recordedDate	DateTime	stored	The date and time when this evidence was documented or recorded in the clinical record - supports temporal sequencing of diagnostic reasoning and evidence accumulation Example: `"2024-03-15T14:30:00Z"`	Optional
recordedBy	Practitioner	stored	Reference to the healthcare practitioner who documented this evidence and its relationship to the diagnosis - ensures accountability and supports clinical workflow tracking Example: `"practitioner-789"`	Optional
hasStructuredEvidence	boolean	calculated	Computed indicator showing whether this evidence record contains at least one structured reference (observation, labResult, or imagingStudy) - useful for data quality assessment and completeness metrics	Optional
evidenceCount	number	calculated	Computed count of the total number of evidence items linked to this record (sum of non-null observation, labResult, and imagingStudy references) - supports evidence strength assessment and diagnostic confidence scoring	Optional

Examples

Example 1

{
  "@type": "DiagnosisEvidence",
  "diagnosis": "encounter-dx-001",
  "code": {
    "code": "15220000",
    "system": "SNOMED-CT",
    "display": "Laboratory test"
  },
  "detail": "Elevated white blood cell count and positive bacterial culture strongly support diagnosis of community-acquired pneumonia",
  "observation": "observation-lab-12345",
  "labResult": "Lab #LAB-2024-03456: Blood culture positive for Streptococcus pneumoniae, WBC 18,500/μL with left shift",
  "recordedDate": "2024-03-15T14:30:00Z",
  "recordedBy": "practitioner-101",
  "_comment": "hasStructuredEvidence: true, evidenceCount: 2"
}

Example 2

{
  "@type": "DiagnosisEvidence",
  "diagnosis": "encounter-dx-002",
  "code": {
    "code": "363679005",
    "system": "SNOMED-CT",
    "display": "Imaging"
  },
  "detail": "Radiographic findings demonstrate classic features of community-acquired pneumonia with right lower lobe involvement",
  "imagingStudy": "Radiology #RAD-2024-07890: Chest X-ray PA and lateral - Right lower lobe consolidation with air bronchograms, no pleural effusion. Findings consistent with acute bacterial pneumonia.",
  "recordedDate": "2024-03-15T11:45:00Z",
  "recordedBy": "practitioner-202",
  "_comment": "hasStructuredEvidence: true, evidenceCount: 1"
}

Example 3

{
  "@type": "DiagnosisEvidence",
  "diagnosis": "encounter-dx-003",
  "code": {
    "code": "5880005",
    "system": "SNOMED-CT",
    "display": "Physical examination"
  },
  "detail": "Physical examination reveals classic signs of pneumonia including crackles on auscultation, increased tactile fremitus, and dullness to percussion over the right lower lung field",
  "observation": "observation-exam-67890",
  "recordedDate": "2024-03-15T10:15:00Z",
  "recordedBy": "practitioner-101",
  "_comment": "hasStructuredEvidence: true, evidenceCount: 1"
}