Table 2.

Twenty-six terms in the final terminology, with definitions, examples and Fleiss’s Kappa from Phase 4 evaluation. Example words in italics indicate clinical concepts associated with each other through the relationship.

Relationship concepts	Definition	Example	kappa
finding/history of	Any simple statement of fact about a patient, including a past or current diagnosis, a symptom, physical finding, test result, etc.; no inference or interpretation involved	The patient had slurred speech	0.39
absence of finding	Any simple statement of fact about something absent, currently or in the past; no inference or interpretation involved	She had no history of easy bleeding or bruising	0.65
finding altered by activity	An observation (by clinician or patient) that a finding is altered (increased, relieved, etc.) by some action (physical activity, medication, etc.)	She noted shortness of breath on exertion	0.06
findings co-occurrence	Findings are related to each other in some temporal or topographical way	The bruising began shortly after she had had sore throat, coryza, and malaise	0.24
finding suggests condition	A condition is inferred by presence of a finding, or a finding can be explained by condition	The pink sputum suggests hemoptysis	0.69
finding suggests condition is not present	Finding rules out or argues against the condition	These results essentially rule out a platelet disorder	0.27
finding does not suggest condition	Finding does not support the condition, but cannot rule out the condition	Elevation of blood sugar in a patient receiving intravenous glucose does not imply the presence of diabetes.	-0.01
finding absence argues against condition	Absence of finding rules out or argues against the condition	The normal blood pressure argues against the HELLP syndrome	0.31
finding/condition due to intervention	Adverse effects, side effect or complication of a treatment or procedure	Medications are typically thought to trigger this disorder; exposure to antibiotics such as cephalosporins, which this patient received, commonly precedes the rash	0.55
finding/condition suggests risk of some other condition	Inference that a condition might be present based on the presence of some fact about the patient	HIV-positive patients are at risk for a variety of lesions in the nervous system	0.00
differential diagnosis	Consideration of multiple explanatory conditions for the presence of some observed fact or inferred condition	Other causes of an isolated elevated aPTT include lupus anticoagulants, factor deficiencies, factor inhibitors, and severe cases of von Willebrand’s disease	0.70
therapy	A decision to initiate or continue a therapeutic activity	The patient began to receive levofloxacin	0.49
discontinue therapy	A decision to cease a therapeutic activity	When the Gram’s staining and culture from his biopsy were negative, all antibiotic treatment was discontinued	0.81
therapy indicated/considered	A recommendation that a therapeutic activity should be initiated (or continued) based on clinical assessment	A trial of glucocorticoids could be considered for relief of symptoms if the patient’s initial headache persists	0.40
therapy not indicated	A recommendation that a therapeutic activity should be not initiated (or should be discontinued) based on clinical assessment	Inadvertent use of quinolone monotherapy to treat tuberculosis facilitates the emergence of resistant strains and may delay a diagnosis by decreasing the sensitivity of sputum culture	-0.01
therapy not available	Statement that a therapeutic activity, whether recommended or not, is not an available or appropriate option	With regard to the patient’s dysarthria, her age, smoking, hypertension, hyperlipidemia, and family history all arouse concern about stroke, although she is beyond the window for any therapy to prevent acute stroke	0.16
progress and prognosis	An assessment of current or future change in a clinical condition	During this time, he had complete resolution of his skin abnormalities, with no recurrence after discontinuation of prednisone treatment	0.41
diagnostic/assessment procedure indicated	A recommendation that an assessment activity should be initiated (or continued) based on clinical assessment	In this case, given the history that is suggestive of hemoptysis, imaging studies are indicated	0.43
intention of intervention	The intended reason for carrying out an intervention to assist with an inference or alteration of a patient condition	In a patient with acute cough, the history and physical examination are key to determining whether imaging is needed	0.01
procedure performed	A statement that some intentional activity occurred	A lumbar puncture was performed [on patient]	0.36
activity description	Report of patient performing some activity	The patient reported strict adherence to medications	-0.03
description of knowledge/experience	A statement of medical knowledge or clinical experience that may be relevant to the patient’s findings, conditions or decision-making	Many acquired bleeding diatheses have no obvious hereditary component	0.40
has feature	A statement of some (nontopographical, nontemporal) attribute of a finding	Chest radiography showed a wedge-shaped opacity in the right lower lobe with air bronchograms	0.19
location	A statement about a topographical aspect of a finding	During the week before presentation, she also noted pain in her right elbow and both knees	0.03
time	A statement about a temporal aspect of a finding	She recalled that she first noticed difficulty speaking 4 days before presentation	0.66
causes	A statement of medical knowledge causal relationships between findings /conditions or an inference that such as relationship is present in the patient	If systemic release of toxins occurs, a diffuse pustular variant of the toxic shock syndrome can also occur	0.20
other relation (please explain)	Statements that cannot be characterized by one of the above	N/A	0.05