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Design Guidance for Terminology Elaboration (PDF format)

Guidance – Terminology Elaboration

Introduction

The Design Guidance – Terminology Elaboration document provides recommendations on how additional explanatory information may be entered at terminology user interfaces. The aim of the guidance is to provide clinicians with the freedom and flexibility to comprehensively and accurately express their notes in a note-taking environment utilizing a SNOMED CT® database which may use:

Forms, where the user selects set options rather than entering text
Single concept matching, where the user enters a note for a single clinical concept and selects an appropriate match returned by the SNOMED CT database
Text parser matching, where the user enters textual notes and the system matches words and phrases against the SNOMED CT database

Summary of Guidance

Guidance is given on how to add additional information to a SNOMED CT expression when the clinician believes the encoding on its own does not provide sufficient meaning. Elaboration may involve:

Adding unstructured text to the expression to give the expression further meaning
Finding a SNOMED CT expression and adding text to it, as in a single concept matching approach
Matching a SNOMED CT expression from within a passage of text and leaving some of the text itself un-encoded but associated with the encoded expression
Adding a qualifier to a SNOMED CT expression, using the qualifiers offered by the system, such as the severity of a condition
Adding or selecting numerical or date and time values for a SNOMED CT expression