What is the Context?
SNOMED CT (Systematized Nomenclature of Medicine - Clinical Terms) is a structured clinical vocabulary used in electronic health records (EHRs). 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 used in health information, supporting the effective recording of clinical data and ultimately improving patient care.
Meddbase Clinical Forms can utilise SNOMED CT, enabling seamless integration of standardized clinical terms into patient records. This ensures consistent and accurate documentation for healthcare providers, allowing them to manage patient data effectively. Additionally, SNOMED CT matches are considered by the Multilex Clinical Decision Support engine when prescribing drugs in Meddbase, helping to ensure appropriate and safe prescribing practices.
An understanding of SNOMED CT terms in Meddbase is required for this article, to learn more about SNOMED in Meddbase, please read Working with SNOMED CT terms in Meddbase first.
What is the Purpose of this Article?
This article provides an overview of the SNOMED Review Screen within Meddbase, explaining how healthcare providers can use it to manage and review SNOMED CT codes associated with a patient. It outlines how to enable the SNOMED Review Screen and where to find it, along with how to view and manage SNOMED codes within the system.
This article is broken down into the following sections:
- What is the SNOMED Review Screen?
- Enable the SNOMED CT Review Screen
- Where to Find the SNOMED Review Screen
- SNOMED Review Screen Layout
- Filtering the SNOMED Review Screen
- Modifying SNOMED Codes
What is the SNOMED Review Screen?
The SNOMED Review Screen in Meddbase provides a central place to view and manage all SNOMED CT codes associated with a patient’s record. It allows users to easily review and manage these codes without needing to go into each appointment or clinical form. From this screen, users can take actions such as confirming, negating, or deleting codes.
Enable the SNOMED CT Review Screen
To enable the SNOMED Review Screen for your entire chamber, follow these steps:
- Navigate to Admin > Configuration > Appointments.
- Tick Enable SNOMED Review Screen
Where to Find the SNOMED Review Screen
You can access the SNOMED Review Screen from the following areas:
-
The Patient’s Medical History: Available from the Patient Record page.
- Patient Record > Medical History > Show Snomed Codes
- The Appointment’s Consultation Suite: Found within the consultation suite.
SNOMED Review Screen Layout
The SNOMED Review Screen displays all SNOMED CT codes associated with a patient in a table format, showing key details for each code, including:
- Severity Level: Indicates whether the code is classified as major or minor.
- Date and Time First Identified: Shows when the SNOMED code was initially recorded.
- SNOMED Concept Code: Lists the specific SNOMED code used.
- Field and Form Location: Specifies where the SNOMED code was recorded in the form.
- Recorded Context: Details the data entered in the CF field that triggered the code.
- Actions: Provides options to confirm, negate, or delete the SNOMED concept.
Filtering the SNOMED Review Screen
On the left-hand side of the SNOMED review page, you can filter results based on:
-
Status
- Active - Codes which are active on the patient's medical record.
- Deleted - Codes which have been "Deleted" and are not associated with the patient's medical record.
- History - Codes which have been modified from Active, such as Negated.
- Years - Filter by the years the SNOMED code was generated.
-
Severity
- Delete - This will filter the view to show SNOMED links which have been marked as deleted.
- Major - This will filter the view to show SNOMED links which have been confirmed and flagged as major. This will apply to findings and disorders.
- Minor - This will filter the view to show SNOMED links which have been confirmed and flagged as minor. This will apply to findings and disorders.
- Confirmed - This will filter the view to show SNOMED links which have been marked as positive.
- Negative - - This will filter the view to show SNOMED links which have been negated.
- System Suggested - This will filter the view to show System Suggested SNOMED links which need to be actioned.
- Use Cases - This will filter the view to show codes which are used to inform preparation warnings through the Clinical Decision Support Engine when Prescribing.
Use Cases
The Use Cases filter is a crucial feature within the SNOMED page. This filter provides an overview of all SNOMED concept codes that interact with the Clinical Decision Support (CDS) engine during the prescribing process.
By using this filter, clinicians can review and manage these SNOMED codes, identifying any that may be invalid or not applicable to the patient. This ensures that only accurate and relevant codes are associated with a patient’s record, which in turn helps maintain the accuracy and safety of prescribed treatments.
The filter also allows clinicians to see which SNOMED codes will trigger preparation warnings, making it easier to confirm or negate system-suggested codes. By ensuring only relevant terms are active, clinicians can be confident that the CDS engine is providing appropriate alerts and recommendations based on the patient’s current needs.
To read more about clinical decision support in Meddbase and our recommendations for optimisation, please follow this link.
Modifying SNOMED Codes
From the SNOMED Review Screen, you can manage the associated codes in several ways. You have the ability to:
- Confirm: Confirm the accuracy of the SNOMED code by Selecting Positive or Major/Minor.
- Negate: Indicate that the code is not applicable.
- Delete: Remove the code from the patient's record completely.
By modifying the SNOMED code status, you will reflect what codes are sent to the Clinical Decision Support Engine, ensuring accurate and up-to-date preparation warnings when Prescribing.
For more detailed information on working with SNOMED CT terms in Meddbase, please refer to our article Working with SNOMED CT terms in Meddbase.
Review Date
This article was last updated on 26th November 2024.