Working with SNOMED CT terms in Meddbase

Article author
Greg Pietras
  • Updated

What is the context?


SNOMED CT is a structured clinical vocabulary for use in an electronic health record. It is the most comprehensive and precise clinical health terminology product in the world. The primary purpose of SNOMED CT is to encode the meanings that are used in health information and to support the effective recording of clinical data with the aim of improving patient care.

Meddbase Clinical Forms can utilise SNOMED CT. 

What is the purpose of the article?


This article will walk you through important things to note when working with SNOMED CT codes/terms in Meddbase from a Clinical Safety perspective.

The article will cover the following topics:

Clicking on Gifs and images enlarges them.

Configuring Advanced Clinical Form options


There are advanced settings in Meddbase that affect Clinical Form behaviour and enable additional features.

One of these features allows using SNOMED CT coding on Clinical Forms.

Click here for a detailed article.

 

Matching Clinical Form entries to SNOMED CT codes/terms


Once SNOMED CT coding has been activated, whilst typing/dictating into a Clinical Form field, you will notice a pop-up window with suggestions of words and phrases based on what's being typed/dictated. There are 2 types of suggestions you will see:

  1. Regular predictive text (shown in Black font) - Meddbase NLP (Natural Language Processing) engine suggests words of phrases. Clicking on a suggestion populates it into the field.
  2. SNOMED CT code matches (shown in Blue font) - each field may have a number of clinical terms attached. 

The Meddbase NLP (Natural Language Processing) engine continuously submits the text to the SNOMED CT service in an attempt to match what is being typed/dictated with SNOMED CT codes/terms. Any matches that are found will be added as Tentative against the patient. The tentative matches can then be confirmed, negated or deleted. All* SNOMED CT matches are taken into account by the Multilex Clinical Decision Support engine when prescribing drugs in Meddbase.

*DELETED matches are not taken into account.

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Successful entry into a Clinical Form field

Meddbase Clinical Forms can auto-save entries or require user action to save. This depends on the type of field used:

  • Free text field/Numerical data field entries auto-save - when typing/dictating into a Free Text (notes) field or a Numerical Data, e.g. BMI, field on a Clinical Form in Meddbase, the outline of the field will turn GREEN when you click outside of the field or into a subsequent field. This indicates the entry was saved*. 

*When text is entered into a Numerical Data field, where a number is expected, the outline of the field turns Red to indicate the entry was not saved.

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  • Tables, Dropdown Menus, Checkboxes, Radio Buttons, Notes with History field types require action to save entry - when interacting with these field types, an Action is required to save an entry, i.e.:
    • Tables and Notes with History - require clicking the Plus button.png button.
    • Dropdown Menus - require clicking a down arrow Down arrow 2.png and a selection from a list of answers/options.
    • Checkboxes - require a tick in a box Checkbox.png.
    • Radio Buttons - require a tick in a circle Radio button.png.

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Field entry context 

When working with SNOMED CT codes/terms, is it very important to ensure that these terms are correctly attributed to findings, disorders and allergies. It is particularly important in the context of Acute and Repeat drug prescribing in Meddbase.

A Multilex Clinical Decision Support engine in Meddbase provides Preparation Warnings, where drugs are contraindicated in relation to ALL* SNOMED CT codes/term matches (Tentative/ Confirmed/ Negated/ Minor/ Major) for findings, disorders and allergies recorded as part of patient's consultations in Meddbase.

*DELETED matches are not taken into account.

Click here for more details on Prescribing in Meddbase.

Tentative match

In the first instance, a match of text to a SNOMED CT code/term is TENTATIVE, as shown above.

This mean the match 'has been coded by a computer, but not yet confirmed by a human'.

The tentative match is taken into account by the Multilex Clinical Decision Support engine when prescribing drugs. 

 

Confirming a Tentative match

A tentative match other than a finding, disorder or allergy, can simply be Confirmed, which means:

'I agree that this code/term is valid'

In the below example the text entered is:

'This patient has back pain'

  • The text is submitted to SNOMED CT in real time, and 2 codes/terms are TENTATIVELY matched with parts of the entered text: Patient (person) and Backache (finding).
  • The Medical Person clicks Positive to confirm the tentative match for Patient (person).

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Negating a Tentative match

As mentioned in the Field entry context chapter, is it very important to ensure that these terms are correctly attributed to findings, disorders and allergies. It is particularly important in the context of Acute and Repeat drug prescribing in Meddbase, so that drug contraindications are provided accurately by the Clinical Decision Support engine.

A tentative match can be Negated, which means:

'The opposite was meant here'.

In the below example the text entered is:

'Patient does not have Asthma' 

  • The text is submitted to SNOMED CT in real time, and 2 codes/terms are TENTATIVELY matched with parts of the entered text: Patient (person) and Asthma (disorder).
  • However, the full context of the entire entry, where it is clear that the patient DOES NOT have Asthma is NOT taken into account, and thus Asthma (disorder) is recorded against the patient and will result in drug contraindications for Asthma being provided when prescribing drugs to this patient 

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  • It is therefore up to the Medical Person capturing the information to NEGATE the Tentative match, so that no drug contraindications for Asthma are provided when prescribing drugs to this patient.

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Deleting a Tentative match

A tentative match can simply be Deleted, which means:

'I do not want this code/term associated with this patient's record at all'

In the below example the text entered is:

'Patient's father suffered from Anxiety' 

  • The text is submitted to SNOMED CT in real time, and 4 codes/terms are TENTATIVELY matched with parts of the entered text: Patient (person), Father (person), Suffering (finding) and Anxiety (finding).
  • The Medical Person clicks Delete to remove the tentative match for Anxiety (finding), so that the code/term is not associated with this patient's record at all.

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Confirming a Tentative match with Minor or Major severity 

Tentative matches for Findings and Disorders can be confirmed with an indication of Severity:

    • Minor - color coded Yellow

Or

    • Major - color coded Red

In the below example the text entered is:

'Patient suffers from Anxiety' 

  • The text is submitted to SNOMED CT in real time, and 3 codes/terms are TENTATIVELY matched with parts of the entered text: Patient (person), Suffering (finding) and Anxiety (finding).
  • The Medical Person clicks Minor for Anxiety (finding), to indicate minor severity.
  • Once minor severity is set, the Medical Person can click Major, to indicate major severity.

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Severity in Medical Record: Summary

The Medical Record: Summary section of the patient's Medical History displays severity for:

  • Individual confirmed matches confirmed with Minor (Yellow vertical bar) or Major severity (Red vertical bar).
  • Cases that include Episodes containing (a) confirmed match(es) with Minor (Yellow vertical bar) or Major severity (Red vertical bar).

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Click here for more details on Working with the Medical History. 

Review date


This article was last updated on 6th of March 2024