Clinical Diagnosis and Procedure Rules

What ZIMS allows when adding a clinical diagnosis or procedure

Requirements for valid diagnosis:

Medical concern terms (medical issues) come in 4 varieties and one is required:

Medical Condition/Syndrome/Disorder
Clinical Sign
Clinical Finding
Procedure

Only a single medical issue term is allowed in each entry (i.e. one of the above)
Only a single anatomical location is allowed in each entry
Only a single Medical Modifier - Distribution term is allowed in each entry
Only a single Medical Modifier - Duration term is allowed in each entry
Only a single Medical Modifier - Severity term is allowed in each entry
Up to 8 other modifiers not mentioned above. This includes:

Anatomical Modifier - Symmetry
Anatomical Modifier - Other
Medical Modifier - Etiological
Medical Modifier - Other
Complex problem

The order of terms is maintained as entered by the user.

A diagnosis entry must have one and only one medical concern term; if you have a clinical sign and a clinical finding in the same entry, it needs to become 2 entries and you will get a warning.

You can add modifier terms to a diagnosis entry; think of them as adjective and adverbs for the main term. The modifier terms add specificity to the diagnosis entry, but the diagnosis entry can stand by itself without modifiers.

Example: Bronchopneumonia is a Medical condition/Syndrome/Disorder term; it can be a valid diagnosis entry all by itself.

However, I can also add modifier terms to more fully describe the diagnosis.

Example: Bronchopneumonia, acute, severe, right cranial lobe Somebody reading this diagnosis entry has a better “picture” of the medical problem.

Example #2: lameness; A clinical sign that can stand by itself

Lameness, mild, right front limb; a clinical sign with modifiers that give a more complete description of the concern.

Clinical signs, Medical condition/Syndrome/Disorders and Procedures can have duration; they will have a start date and an end date, although most procedures (e.g., surgery) will start and stop on the same date.

Clinical findings are, by definition, the result of a measurement at a point in time; they have no duration (start date = end date). When you pick a clinical finding, you are not asked for an end date.

Clinical signs and clinical findings entries can be associated with Medical condition/Syndrome/Disorders entries.

Example:
• Fever (clinical finding)
• Decreased appetite (clinical sign)
• Decreased activity (clinical sign)
• Cough (clinical sign)
• Elevated white blood cell count (clinical finding)
• Increased density of lung area on x-ray film (clinical finding)

All lead to the conclusion (diagnosis) that the animal has pneumonia (Medical condition/Syndrome/Disorders)

All the clinical signs can be associated (linked) with the pneumonia entry. If you never reach a diagnosis, and only have a cluster of signs and findings, then you cannot associate these entries with anything.

All medical concern/procedure entries can be associated with clinical notes; in this case they act like keywords for the clinical note, but rather than have to type in the keywords, you just pick from the list of existing signs, findings and procedures that are valid for the date of the clinical note and check the appropriate “keywords” for the clinical note.

Confidence and Unresolvable only apply to Medical condition/Syndrome/Disorders terms (how confident are you that the pneumonia diagnosis is correct and can the problem be fixed?).

Revised 5 March 2025
* Species360 Organizational name change added on 07/18/2016