Reference table
Clinical vocabulary
Lists the coding systems and terminologies the record uses, with the fields they populate and the version that each mapping refers to.
The patient record codes its clinical facts against published terminologies rather than free text. This page lists the coding systems and standards the record uses, the field each one populates, and the version that a mapping refers to.
Clinical coding systems
Each clinical coding system populates a defined field in the record, so a diagnosis, a finding and a laboratory result each carry a code a second reader resolves the same way.
| Coding system | What it codes | Field it populates | Version |
|---|---|---|---|
| ICD-11 | Diagnoses and problems | The diagnosis on an encounter | Eleventh revision |
| SNOMED CT | Clinical findings, problems and procedures | Coded findings across the record | International Edition |
| LOINC | Laboratory tests and observations | The identity of a laboratory result | Current release |
ICD-11 is authoritative for a diagnosis
A diagnosis is stored against its ICD-11 code. Where a reviewer or an external system asks for the older ICD-10 code, the record derives it on demand from a maintained mapping, so the authoritative code stays single and current.
Messaging and imaging standards
Messages to and from other hospital systems, and imaging studies, carry their own standards. orophin reads and writes these at the site boundary and marks the origin of each message.
| Standard | What it carries | Where it applies | Version |
|---|---|---|---|
| HL7 v2 | Clinical messages with external systems | Inbound and outbound message interfaces | Version 2 |
| FHIR R4 | Structured clinical resources | Resources exposed to and read from other systems | R4 |
| DICOM | Imaging studies | Studies read in the image study viewer | Current edition |
| ABDM | National health-data exchange in India | The patient's national health account | Current specification |
Coded demographics
Two demographic fields are coded and held apart, because they answer different questions. Biological sex drives dosing and reference ranges; gender records how the patient is addressed and administered.
| Field | Purpose | Read by |
|---|---|---|
| Biological sex | Clinical, drives dosing and reference ranges | Medication and result review |
| Gender | Administrative, how the patient is addressed | Registration and correspondence |
How a mapping refers to a version
A coded entry records the version of the system it was made against. A diagnosis coded to a given ICD-11 release keeps that reference, and a later release leaves the earlier diagnosis as it stood. This is the same effective dating the record applies to a placed order and a raised charge.
code string Required | The value drawn from the coding system. |
system string Required | The coding system the value belongs to. |
version string Required | The release of the system the value was coded against. |
display string | The human-readable label carried alongside the code. |
Common questions
Why does a diagnosis use ICD-11 rather than ICD-10?
ICD-11 is the authoritative diagnosis code in the record. The older ICD-10 value is derived on demand from a maintained mapping when a reviewer or an external system asks for it, so one code stays authoritative.
Which system codes a laboratory result?
LOINC identifies the test and the observation, and the result value itself is captured on the form attached to the order. SNOMED CT codes the wider clinical findings that sit across the record.
What holds a coded term across an external interface?
orophin maps a coded term in another system onto the vocabulary the record uses, so the meaning is kept as the message crosses the boundary. Read more on terminology mapping.
Read how each entry is timed and attributed in the record model.