Published

Clinical Observation / Diagnosis

vr.wm-act-046 · wm-act-046-clinical-observation-diagnosis

Represent one source-qualified clinical assertion, explicitly profiled as an observation result, clinical impression or diagnosis-condition, so agents can interpret evidence, status, uncertainty and lineage without conflating the assertion with the patient, encounter or disease entity.

World Models Activities and processes ACT.HCR

Bundle → Layer → Finding → Questions Classifiers What it is Why it exists Distinguishing features What robots and AI may and may not do Moral aspects Owners Links to other meta-models Identity and identifiers Direct properties Recognition Capabilities and actions Hazards and failure modes Standards and interfaces Context of use Sources

Bundle → Layer → Finding → Questions Filled

6 bundles · 12 layers · 24 findings · 72 questions

Assertion identity, profile, subject and boundary Groups governed clinical assertion context for assertion identity, profile, subject and boundary.

Assertion profile, identity, source and lineage

Groups source-qualified clinical context for assertion profile, identity, source and lineage.

Assertion profile, kind, scope, specialty and semantic boundary

Records assertion profile, kind, scope, specialty and semantic boundary as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish assertion profile, kind, scope, specialty and semantic boundary? classification
Who or what supplied, performed, recorded, interpreted or accepted responsibility for assertion profile, kind, scope, specialty and semantic boundary, using which method, evidence and authority? quality
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to assertion profile, kind, scope, specialty and semantic boundary, and how may it be validated, challenged, corrected or retained? privacy

Assertion identifier, source, version, predecessor, successor and lineage

Records assertion identifier, source, version, predecessor, successor and lineage as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish assertion identifier, source, version, predecessor, successor and lineage? identity
Who or what supplied, performed, recorded, interpreted or accepted responsibility for assertion identifier, source, version, predecessor, successor and lineage, using which method, evidence and authority? authority
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to assertion identifier, source, version, predecessor, successor and lineage, and how may it be validated, challenged, corrected or retained? retention

Subject, focus, encounter and phenomenon boundaries

Groups source-qualified clinical context for subject, focus, encounter and phenomenon boundaries.

Subject, focus, related person, group and encounter binding

Records subject, focus, related person, group and encounter binding as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish subject, focus, related person, group and encounter binding? relationship
Who or what supplied, performed, recorded, interpreted or accepted responsibility for subject, focus, related person, group and encounter binding, using which method, evidence and authority? ownership
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to subject, focus, related person, group and encounter binding, and how may it be validated, challenged, corrected or retained? access

Observable question, result, finding, diagnosis, condition and disease distinction

Records observable question, result, finding, diagnosis, condition and disease distinction as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish observable question, result, finding, diagnosis, condition and disease distinction? definition
Who or what supplied, performed, recorded, interpreted or accepted responsibility for observable question, result, finding, diagnosis, condition and disease distinction, using which method, evidence and authority? temporal
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to observable question, result, finding, diagnosis, condition and disease distinction, and how may it be validated, challenged, corrected or retained? validation

Observation design, acquisition and result Groups governed clinical assertion context for observation design, acquisition and result.

Observable, method, specimen, device, procedure and request

Groups source-qualified clinical context for observable, method, specimen, device, procedure and request.

Observation code, property, system, time aspect, scale, method and body site

Records observation code, property, system, time aspect, scale, method and body site as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish observation code, property, system, time aspect, scale, method and body site? composition
Who or what supplied, performed, recorded, interpreted or accepted responsibility for observation code, property, system, time aspect, scale, method and body site, using which method, evidence and authority? state
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to observation code, property, system, time aspect, scale, method and body site, and how may it be validated, challenged, corrected or retained? interoperability

Specimen, device, procedure, service request, protocol and calibration binding

Records specimen, device, procedure, service request, protocol and calibration binding as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish specimen, device, procedure, service request, protocol and calibration binding? relationship
Who or what supplied, performed, recorded, interpreted or accepted responsibility for specimen, device, procedure, service request, protocol and calibration binding, using which method, evidence and authority? lifecycle
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to specimen, device, procedure, service request, protocol and calibration binding, and how may it be validated, challenged, corrected or retained? decision

Value, unit, range, component, derivation and interpretation

Groups source-qualified clinical context for value, unit, range, component, derivation and interpretation.

Result value type, quantity, unit, code, text, media, absence and uncertainty

Records result value type, quantity, unit, code, text, media, absence and uncertainty as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish result value type, quantity, unit, code, text, media, absence and uncertainty? measurement
Who or what supplied, performed, recorded, interpreted or accepted responsibility for result value type, quantity, unit, code, text, media, absence and uncertainty, using which method, evidence and authority? provenance
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to result value type, quantity, unit, code, text, media, absence and uncertainty, and how may it be validated, challenged, corrected or retained? exception

Component, panel, member, reference range, flag, interpretation and derived-from

Records component, panel, member, reference range, flag, interpretation and derived-from as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish component, panel, member, reference range, flag, interpretation and derived-from? relationship
Who or what supplied, performed, recorded, interpreted or accepted responsibility for component, panel, member, reference range, flag, interpretation and derived-from, using which method, evidence and authority? privacy
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to component, panel, member, reference range, flag, interpretation and derived-from, and how may it be validated, challenged, corrected or retained? security

Diagnostic reasoning, evidence and clinical assertion Groups governed clinical assertion context for diagnostic reasoning, evidence and clinical assertion.

Signs, symptoms, observations, reports and evidence basis

Groups source-qualified clinical context for signs, symptoms, observations, reports and evidence basis.

Subjective symptom, objective sign, observation, report, image and document evidence

Records subjective symptom, objective sign, observation, report, image and document evidence as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish subjective symptom, objective sign, observation, report, image and document evidence? evidence
Who or what supplied, performed, recorded, interpreted or accepted responsibility for subjective symptom, objective sign, observation, report, image and document evidence, using which method, evidence and authority? retention
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to subjective symptom, objective sign, observation, report, image and document evidence, and how may it be validated, challenged, corrected or retained? identity

Evidence relevance, quality, conflict, missingness and alternative explanation

Records evidence relevance, quality, conflict, missingness and alternative explanation as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish evidence relevance, quality, conflict, missingness and alternative explanation? quality
Who or what supplied, performed, recorded, interpreted or accepted responsibility for evidence relevance, quality, conflict, missingness and alternative explanation, using which method, evidence and authority? access
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to evidence relevance, quality, conflict, missingness and alternative explanation, and how may it be validated, challenged, corrected or retained? classification

Impression, diagnosis, differential, verification and condition context

Groups source-qualified clinical context for impression, diagnosis, differential, verification and condition context.

Clinical statement, code, category, severity, stage, body site and context

Records clinical statement, code, category, severity, stage, body site and context as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish clinical statement, code, category, severity, stage, body site and context? classification
Who or what supplied, performed, recorded, interpreted or accepted responsibility for clinical statement, code, category, severity, stage, body site and context, using which method, evidence and authority? validation
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to clinical statement, code, category, severity, stage, body site and context, and how may it be validated, challenged, corrected or retained? relationship

Working, provisional, differential, confirmed, refuted, error and confidence state

Records working, provisional, differential, confirmed, refuted, error and confidence state as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish working, provisional, differential, confirmed, refuted, error and confidence state? state
Who or what supplied, performed, recorded, interpreted or accepted responsibility for working, provisional, differential, confirmed, refuted, error and confidence state, using which method, evidence and authority? interoperability
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to working, provisional, differential, confirmed, refuted, error and confidence state, and how may it be validated, challenged, corrected or retained? measurement

Participants, authority, time and clinical context Groups governed clinical assertion context for participants, authority, time and clinical context.

Performer, recorder, author, interpreter, asserter and responsibility

Groups source-qualified clinical context for performer, recorder, author, interpreter, asserter and responsibility.

Performer, device, recorder, author, interpreter, asserter and informant role

Records performer, device, recorder, author, interpreter, asserter and informant role as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish performer, device, recorder, author, interpreter, asserter and informant role? authority
Who or what supplied, performed, recorded, interpreted or accepted responsibility for performer, device, recorder, author, interpreter, asserter and informant role, using which method, evidence and authority? decision
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to performer, device, recorder, author, interpreter, asserter and informant role, and how may it be validated, challenged, corrected or retained? evidence

Organization, care team, specialty, credential, delegation, signature and accountability

Records organization, care team, specialty, credential, delegation, signature and accountability as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish organization, care team, specialty, credential, delegation, signature and accountability? ownership
Who or what supplied, performed, recorded, interpreted or accepted responsibility for organization, care team, specialty, credential, delegation, signature and accountability, using which method, evidence and authority? exception
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to organization, care team, specialty, credential, delegation, signature and accountability, and how may it be validated, challenged, corrected or retained? quality

Effective, specimen, onset, issued, recorded and context times

Groups source-qualified clinical context for effective, specimen, onset, issued, recorded and context times.

Effective period, instant, specimen collection, onset, abatement and duration

Records effective period, instant, specimen collection, onset, abatement and duration as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish effective period, instant, specimen collection, onset, abatement and duration? temporal
Who or what supplied, performed, recorded, interpreted or accepted responsibility for effective period, instant, specimen collection, onset, abatement and duration, using which method, evidence and authority? security
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to effective period, instant, specimen collection, onset, abatement and duration, and how may it be validated, challenged, corrected or retained? authority

Issued, authored, recorded, ingested, known time, location, posture, fasting and context

Records issued, authored, recorded, ingested, known time, location, posture, fasting and context as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish issued, authored, recorded, ingested, known time, location, posture, fasting and context? temporal
Who or what supplied, performed, recorded, interpreted or accepted responsibility for issued, authored, recorded, ingested, known time, location, posture, fasting and context, using which method, evidence and authority? identity
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to issued, authored, recorded, ingested, known time, location, posture, fasting and context, and how may it be validated, challenged, corrected or retained? ownership

Lifecycle, correction, refutation, safety and use Groups governed clinical assertion context for lifecycle, correction, refutation, safety and use.

Result, condition, verification and publication lifecycles

Groups source-qualified clinical context for result, condition, verification and publication lifecycles.

Registered, preliminary, final, amended, corrected, cancelled, unknown and entered-in-error

Records registered, preliminary, final, amended, corrected, cancelled, unknown and entered-in-error as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish registered, preliminary, final, amended, corrected, cancelled, unknown and entered-in-error? lifecycle
Who or what supplied, performed, recorded, interpreted or accepted responsibility for registered, preliminary, final, amended, corrected, cancelled, unknown and entered-in-error, using which method, evidence and authority? classification
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to registered, preliminary, final, amended, corrected, cancelled, unknown and entered-in-error, and how may it be validated, challenged, corrected or retained? temporal

Active, recurrence, relapse, inactive, remission, resolved and verification status

Records active, recurrence, relapse, inactive, remission, resolved and verification status as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish active, recurrence, relapse, inactive, remission, resolved and verification status? state
Who or what supplied, performed, recorded, interpreted or accepted responsibility for active, recurrence, relapse, inactive, remission, resolved and verification status, using which method, evidence and authority? relationship
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to active, recurrence, relapse, inactive, remission, resolved and verification status, and how may it be validated, challenged, corrected or retained? state

Amendment, supersession, refutation, decision support and contestability

Groups source-qualified clinical context for amendment, supersession, refutation, decision support and contestability.

Amendment, correction, replacement, duplicate, refutation, retraction and history

Records amendment, correction, replacement, duplicate, refutation, retraction and history as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish amendment, correction, replacement, duplicate, refutation, retraction and history? provenance
Who or what supplied, performed, recorded, interpreted or accepted responsibility for amendment, correction, replacement, duplicate, refutation, retraction and history, using which method, evidence and authority? measurement
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to amendment, correction, replacement, duplicate, refutation, retraction and history, and how may it be validated, challenged, corrected or retained? lifecycle

Clinical use, alert, decision support, risk, limit, review and contestability

Records clinical use, alert, decision support, risk, limit, review and contestability as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish clinical use, alert, decision support, risk, limit, review and contestability? decision
Who or what supplied, performed, recorded, interpreted or accepted responsibility for clinical use, alert, decision support, risk, limit, review and contestability, using which method, evidence and authority? evidence
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to clinical use, alert, decision support, risk, limit, review and contestability, and how may it be validated, challenged, corrected or retained? provenance

Quality, provenance, privacy, retention, interoperability and agents Groups governed clinical assertion context for quality, provenance, privacy, retention, interoperability and agents.

Source quality, provenance, access, consent and confidentiality

Groups source-qualified clinical context for source quality, provenance, access, consent and confidentiality.

Source record, terminology release, mapping, transformation, derivation and quality

Records source record, terminology release, mapping, transformation, derivation and quality as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish source record, terminology release, mapping, transformation, derivation and quality? provenance
Who or what supplied, performed, recorded, interpreted or accepted responsibility for source record, terminology release, mapping, transformation, derivation and quality, using which method, evidence and authority? quality
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to source record, terminology release, mapping, transformation, derivation and quality, and how may it be validated, challenged, corrected or retained? privacy

Sensitivity, consent, purpose, access, redaction, break-glass and disclosure

Records sensitivity, consent, purpose, access, redaction, break-glass and disclosure as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish sensitivity, consent, purpose, access, redaction, break-glass and disclosure? privacy
Who or what supplied, performed, recorded, interpreted or accepted responsibility for sensitivity, consent, purpose, access, redaction, break-glass and disclosure, using which method, evidence and authority? authority
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to sensitivity, consent, purpose, access, redaction, break-glass and disclosure, and how may it be validated, challenged, corrected or retained? retention

Retention, projection, validation and safe agent operation

Groups source-qualified clinical context for retention, projection, validation and safe agent operation.

Retention, hold, disposition, tombstone, correction duty and audit reference

Records retention, hold, disposition, tombstone, correction duty and audit reference as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish retention, hold, disposition, tombstone, correction duty and audit reference? retention
Who or what supplied, performed, recorded, interpreted or accepted responsibility for retention, hold, disposition, tombstone, correction duty and audit reference, using which method, evidence and authority? ownership
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to retention, hold, disposition, tombstone, correction duty and audit reference, and how may it be validated, challenged, corrected or retained? access

FHIR, openEHR, SNOMED, LOINC, ICD, OMOP, DICOM, UCUM projection and loss

Records fhir, openehr, snomed, loinc, icd, omop, dicom, ucum projection and loss as a source-qualified clinical assertion while preserving external clinical masters and the separation between observable, result, interpretation and diagnosis.

Which stable identities, profile, clinical meanings, values and explicit unknowns establish fhir, openehr, snomed, loinc, icd, omop, dicom, ucum projection and loss? interoperability
Who or what supplied, performed, recorded, interpreted or accepted responsibility for fhir, openehr, snomed, loinc, icd, omop, dicom, ucum projection and loss, using which method, evidence and authority? temporal
Which event, effective, specimen, onset, issued, recorded and knowledge times apply to fhir, openehr, snomed, loinc, icd, omop, dicom, ucum projection and loss, and how may it be validated, challenged, corrected or retained? validation

Classifiers Filled

Family: World Models
Category: Activities and processes
Entry kind: aggregate
Navigation path: NAV.ACT.HCR
Domain: ACT.HCR
Industry: Cross-industry
Tags: clinicalobservationdiagnosisact.hcr

What it is Filled

Owns assertion identity and lineage, profile, subject and encounter bindings, source meaning, observation design and value, interpretation, diagnostic statement, evidence-use links, participants and authority, effective and record times, result, verification and clinical statuses, correction and refutation history, quality, privacy, retention and interoperability. Patient, practitioner, encounter, specimen, device, procedure, report, disease, terminology, care action, consent, audit and record masters remain external.

In scope

Clinical assertion profile, identity, source, subject, focus, context, value, interpretation, evidence, uncertainty, participants, authority and time
Observation capture, clinical impression, diagnosis assertion, lifecycle, verification, correction, refutation, privacy, retention, provenance and version-pinned projections

Out of scope

Independent patient, practitioner, encounter, episode, specimen, device, request, procedure, diagnostic report, disease or condition entity, terminology, care plan, treatment, medication, consent, audit or records lifecycles
Treating an observable as a result, result as diagnosis, assertion as disease entity, preliminary as final, clinical status as verification status, refuted as erased or code mapping as source truth
Giving medical advice, autonomously diagnosing, ordering or performing care, operating clinical systems or defining universally applicable professional and legal rules

Why it exists Filled

Distinguishing features Filled

Models one clinical assertion about a patient, keeping observation, interpretation and diagnosis separate.
Keeps preliminary, final, amended, refuted and entered-in-error states distinct.
Binds assertions to terminologies such as SNOMED CT or LOINC by reference, not by copying them.
Differs from the disease entity, which is general knowledge, and from the diagnostic report.

What robots and AI may and may not do Filled

Must not

Diagnose, refute or change the verification status of a condition.
Present decision-support output as a confirmed diagnosis.
Delete or overwrite an assertion instead of marking it entered-in-error.
Treat absent data as a negative finding.
Disclose diagnoses beyond the care and consent context.

Only with a human decision

Making or refuting a diagnosis.
Communicating a diagnosis to the patient.
Releasing sensitive diagnoses such as mental health or HIV status.

May

Capture observation values with units and method from devices or forms.
Map local codes to standard terminologies with a stated mapping version.
Flag values outside reference ranges for clinician review.
Propose a candidate condition as decision support, labelled as such.

Moral aspects Filled

Diagnoses shape treatment, insurance and stigma; errors cause direct harm.
Patients have rights to access and correct their records.
Decision support can carry biases from training populations.

Who is affected

Patients
Clinicians
Family members and carers

Owners Filled

Steward

Dimension owner and clinical assertion governance mandate

Roles

Clinical assertion steward: Own model profile, boundary, namespace, lifecycle and quality rules.
Observer or performer: Own source-qualified acquisition and method statements within competence.
Recorder or data enterer: Preserve source fidelity and distinguish entry from clinical responsibility.
Interpreter or responsible asserter: Own interpretation or diagnosis, evidence basis, uncertainty and signature.
Terminology and interoperability steward: Own versioned code, unit and projection mappings with loss declarations.
Privacy and consent steward: Own purpose-bound access, disclosure, redaction and break-glass policy.
Clinical safety reviewer: Own correction impact, contested results and downstream-use review.
Records and assurance steward: Own retention, holds, provenance, auditability and disposition evidence.

Links to other meta-models Filled

references

WM-ACT-018 Encounter - Record the candidate inverse containment and clinical context without owning Encounter lifecycle.
WM-LIV-021 Disease / Biological Condition - Bind the external condition or disease entity while keeping the diagnosis assertion independently identified and qualified.
Patient, Related Person, Practitioner, Organization, Care Team, Specimen, Device, Request, Procedure and Diagnostic Report models - Resolve authoritative clinical participants and acquisition context without lifecycle cascade.
Evidence, Provenance, Consent, Access, Audit and Record models - Bind evidence, authority, protected use and reconstructable history while their masters retain execution semantics.

aligned

FHIR R5, openEHR RM 1.1.0, SNOMED CT, LOINC 2.82, ICD-11 2026-01, OMOP CDM 5.4, DICOM and UCUM - Project version-pinned clinical and analytic representations with explicit profile, maturity, terminology, unit and loss declarations.

neighbor

WM-ACT-018 Encounter - Encounter may contain or contextualize assertion instances, but owns its own participants, location, service and lifecycle. The ledger relation is candidate only.
WM-LIV-021 Disease / Biological Condition - The disease or biological-condition master owns the condition entity or class. This model owns a source-qualified assertion that a subject has, may have or does not have a condition at a stated verification and clinical status.
Patient, Related Person, Practitioner, Organization and Care Team - External identity and role masters own people and organizations. This assertion records role-qualified references, participation, informant status, delegation and responsibility.
Specimen, Device, Service Request, Procedure and Diagnostic Report - External masters own acquisition objects, performed procedures and report lifecycle. The assertion binds the exact sources, methods and report membership needed for interpretation.
SNOMED CT, LOINC, ICD-11, UCUM and other terminology masters - Terminology systems own concept and unit releases. This assertion preserves original source meaning, selected mappings, versions, mapping responsibility and loss.
Treatment, Care Plan, Decision Support and Clinical Action - This model may expose clinically usable assertions and safety limitations but never turns evidence into an autonomous treatment order or action.

parent

WM-LIV-021

What else AI and robots need to interact with it Filled

Sources Filled

FHIR R5 Observation - Health Level Seven International
FHIR R5 Condition - Health Level Seven International
FHIR R5 DiagnosticReport - Health Level Seven International
FHIR R5 ClinicalImpression - Health Level Seven International
openEHR Reference Model EHR Information Model - openEHR Foundation
SNOMED CT Concept Model - SNOMED International
Clinical Finding and Disorder - SNOMED International
LOINC Users' Guide: Clinical observations and measures - Regenstrief Institute
ICD API Supported Classifications, Versions and Languages - World Health Organization
ICD API version 2 documentation - World Health Organization
OMOP Common Data Model v5.4 - Observational Health Data Sciences and Informatics
DICOM Standard PS3.3 Information Object Definitions - DICOM Standards Committee
The Unified Code for Units of Measure - Regenstrief Institute
Regulation (EU) 2016/679 General Data Protection Regulation - European Union
PROV-O: The PROV Ontology - World Wide Web Consortium
Date and Time on the Internet: Timestamps - Internet Engineering Task Force

Open questions

Approve or reject the WM-ACT-018 containment edge and define cardinality, encounter context, cross-encounter assertion and non-cascade semantics.
Create specialty assertion profiles for laboratory, pathology, imaging, genomics, vital signs, mental health and patient-reported outcomes.
Create jurisdiction and institution profiles for diagnostic authority, signature, consent, disclosure, correction, retention and access.
Test release-pinned FHIR, openEHR, SNOMED CT, LOINC, ICD-11, OMOP CDM, DICOM and UCUM mappings with mapping-loss and round-trip evidence.
Obtain supplemental Claude or Grok review and resolve any material challenge before canonical promotion.
Claude and Grok each timed out on one bounded attempt; no independent external result was admitted.
WM-ACT-018 Encounter CONTAINS WM-ACT-046 is candidate metadata and not an approved composition edge.
Specialty-specific diagnostics, pathology, genomics, imaging, laboratory, vital-sign, mental-health and patient-reported outcome profiles remain deferred.
FHIR R5 resources are Trial Use at varied maturity, ClinicalImpression is maturity level 1, and full SNOMED, LOINC, ICD, OMOP and DICOM conformance requires release-pinned implementation testing.

Machine files

Card as JSON Specification AGENTS.md Source Card backlog vercy.card/1

Provenance

world-models research · reviewable-draft

Built from: models/wm-act-046-clinical-observation-diagnosis/spec.yaml, ver-cy/world-models/card-supplements/wm-act-046-clinical-observation-diagnosis.json