医疗报告结构与来源检查

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.

Required manifest fields

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.

MedDRA

• ICH developed MedDRA for regulatory information about human medical products.
• The current released English guide is MedDRA 29.1, September 2026; a release date is not a universal study or regulatory implementation date.
• MedDRA uses a multiaxial hierarchy and version-specific currency/relationships.
• State exact version and language.
• Use the study/sponsor-authorized version, official licensed files, and current Points to Consider.
• Do not assume the newest release is the required release.

The aggregate adverse-event formatter accepts SOC and PT labels as supplied and does not validate hierarchy, codes, or coding quality.

LOINC

LOINC identifies health observations, measurements, and documents. LOINC 2.83 was released 19 August 2026 and is the current release at this review. Planned monthly releases are a future cadence change; verify actual release files before selecting a version.

• A valid-looking number-checkdigit string is only syntactic evidence.
• The method, property, timing, system/specimen, scale, and version can affect meaning.
• Verify against the official release or authorized terminology service.
• Review the LOINC license and third-party content terms.

SNOMED CT

SNOMED CT concept identifiers are not clinically validated by their numeric shape.

• Use the applicable international edition, national extension, and effective date.
• Verify concept activity, module, description, and reference-set membership.
• Comply with SNOMED International and national licensing/distribution requirements.
• Do not embed or redistribute licensed terminology content through these assets.

ICD-10-CM

ICD-10-CM changes by fiscal-year release and may require encounter, laterality, or placeholder characters.

• Record the exact release, applicable jurisdiction, and service-date range. CDC lists FY27 files for services from 1 October 2026; on this review date (30 September 2026), the FY26 April update still applies to services in its stated date window. File availability does not make a future effective version applicable early.
• Verify with official CDC/CMS files and coding guidance.
• A regex match cannot establish billability, specificity, sequencing, or clinical correctness.
• This skill does not support billing or reimbursement decisions.

UCUM and units

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:

• an authorized rule and version;
• original value/unit;
• converted value/unit;
• precision/rounding rule;
• source-fact and reviewer traceability.

The consistency checker flags missing or inconsistent unit labels but performs no clinical conversion. The terminology checker uses a restricted character screen for UCUM, not the complete UCUM grammar or semantic parser. Do not change a verified expression merely to satisfy that screen; record the limitation for qualified review.

Optional local dictionary

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:

• the dictionary is official, complete, current, or licensed for the use;
• the chosen code is appropriate;
• the clinical statement is true;
• the report is compliant or ready for release.

Without a dictionary, the strongest result is SCHEMA_VALID_SYNTAX_ONLY_REVIEW_REQUIRED.