Note that terms not associated with drugs/substances are in this SOC*, “abuse” regardless of whether they refer to the person or to the condition, as illustrated in the table below: LLT PT Child abuse Child abuse Child abuser Elder abuse Elder abuse Elder abuser (See Section 3.23.2 concerning illegal/criminal acts). 3.23.2 Illegal acts of crime or abuse Terms for illegal acts of crime and abuse (excluding those related to drug/substance abuse) are in SOC Social circumstances, such as LLT Physical assault. LLTs representing the perpetrator are linked to PTs describing the unlawful act committed. PTs representing the victim of unlawful acts generally begin with “Victim of… ”. Example Reported LLT Selected Comment Perpetrator; LLT Patient’s history indicates Sexual offender links to PT Sexual abuse that patient is a known Sexual offender sexual offender in SOC Social circumstances Victim; LLT Childhood sexual assault victim Patient was a childhood Childhood sexual assault links to PT Victim of sexual assault victim victim sexual abuse in SOC Social circumstances 3.24 Medical and Social History – Example Reported LLT Selected History of gastrointestinal bleed Gastrointestinal bleed
Note that “abuse” terms not associated with drugs/substances are in this SOC*, regardless of whether they refer to the person or to the condition, as illustrated in the table below: LLT PT Child abuse Child abuse Child abuser Elder abuse Elder abuse Elder abuser (See Section 3.23.2 concerning illegal/criminal acts). 3.23.2 Illegal acts of crime or abuse Terms for illegal acts of crime and abuse (excluding those related to drug/substance abuse) are in SOC Social circumstances, such as LLT Physical assault. LLTs representing the perpetrator are linked to PTs describing the unlawful act committed. PTs representing the victim of unlawful acts generally begin with “Victim of… ”. Example Reported LLT Selected Comment Patient’s history indicates that patient is a known sexual offender Sexual offender Perpetrator; LLT Sexual offender links to PT Sexual abuse in SOC Social circumstances Patient was a childhood sexual assault victim Childhood sexual assault victim Victim; LLT Childhood sexual assault victim links to PT Victim of sexual abuse in SOC Social circumstances 3.24 – Medical and Social History Example Reported LLT Selected History of gastrointestinal bleed Gastrointestinal bleed
9491-1510_termselptc_r4_4_sep2012.docx