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
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