Existing Wording: Resource Patient - Detailed Descriptions

Patient.gender

Definition

Administrative Gender - the gender that the patient is considered to have for administration and record keeping purposes.

Requirements

Needed for identification of the individual, in combination with (at least) name and birth date. Gender of individual drives many clinical processes.

Comments

The gender might not match the biological sex as determined by genetics, or the individual's preferred identification. Note that for both humans and particularly animals, there are other legitimate possibilities than M and F, though the vast majority of systems and contexts only support M and F. Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific gender aspect of interest (anatomical, chromosonal, social, etc.) However, because these observations are infrequently recorded, defaulting to the administrative gender is common practice. Where such defaulting occurs, rule enforcement should allow for the variation between administrative and biological, chromosonal and other gender aspects. For example, an alert about a hysterectomy on a male should be handled as a warning or overrideable error, not a "hard" error.

Proposed Wording: Requirements

Needed for identification of the individual, in combination with (at least) name and birth date.

Comment:

Suggest you remove the statement "Gender of individual drives many clinical processes." since this contradicts your comments on "Administrative Gender", e.g. (The basic gender included in Patient.gender has a limited use, that of the administrative gender: the gender that the patient is considered to have for administration and record keeping purposes.)

To support your statement "Systems providing decision support or enforcing business rules should ideally do this on the basis of Observations dealing with the specific gender aspect of interest (anatomical, chromosomal, social, etc.)." suggest referring to LOINC codes for Sex assigned at birth (768909) since it may be different from the current Administrative Gender. Also suggest adding reference to LOINC code for Gender Identity in this section.

Summary:

Gender can't drive clinical processes if it's administrative