skills/clinical-reports/references/medical_terminology.md
Terminology selection and coding are clinical/regulatory tasks. The local checker validates manifest shape and code syntax; it does not confirm that a code exists, is current, matches a display, or is clinically appropriate.
For every coded item record:
system: controlled system name;system_uri: canonical identifier supplied by the implementing organization;code;display;version;language;source_fact_id;coding_status: verified_by_qualified_reviewer or unverified;verified_by_role and verified_at when verified.Do not infer a code from narrative text.
The aggregate adverse-event formatter accepts SOC and PT labels as supplied and does not validate hierarchy, codes, or coding quality.
LOINC identifies health observations, measurements, and documents. LOINC 2.82 was released 24 February 2026 and was current when checked.
number-checkdigit string is only syntactic evidence.SNOMED CT concept identifiers are not clinically validated by their numeric shape.
ICD-10-CM changes by fiscal-year release and may require encounter, laterality, or placeholder characters.
Record the original unit exactly and, when an organization uses UCUM, record the verified UCUM expression separately. Do not automatically convert units in a report draft.
Any conversion must have:
The consistency checker flags missing or inconsistent unit labels but performs no clinical conversion.
terminology_validator.py --dictionary <file.json> can compare code/display/version tuples with a caller-supplied local dictionary. The dictionary must be an authorized bounded JSON file.
A match means only “matched this supplied dictionary.” It does not prove:
Without a dictionary, the strongest result is SCHEMA_VALID_SYNTAX_ONLY_REVIEW_REQUIRED.