NHS Data Model and DictionaryNHS Digital
Type:Patch
Reference:1742
Version No:1.0
Subject:SNOMED CT Definitions
Effective Date:Immediate
Reason for Change:Patch
Publication Date:23 October 2019

Background:

The Terminology and Classifications Delivery Service have requested that links to SNOMED CT information in Confluence is replaced with a link to the: SNOMED CT Fact Sheet.

This patch:

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Summary of changes:

Supporting Information
BIOPSY   Changed Description
CLINICAL FINDING   New Supporting Information
CLINICAL SITUATION   New Supporting Information
INTENDED PATIENT PROCEDURE   Changed Description
OBSERVABLE ENTITY   Changed Description
PATIENT PROCEDURE   Changed Description
 
Attribute Definitions
ADDITIONAL UNPLANNED PROCEDURE REQUIRED INDICATOR   Changed Description
FINDING SCHEME IN USE   Changed Description
SITUATION SCHEME IN USE   Changed Description
 
Data Elements
ASSISTIVE TECHNOLOGY FINDING (SNOMED CT)   Changed Description
CODED FINDING (CODED CLINICAL ENTRY)   Changed Description
CODED OBSERVATION (CLINICAL TERMINOLOGY)   Changed Description
CODED PROCEDURE (CLINICAL TERMINOLOGY)   Changed Description
CODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY)   Changed Description
CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT)   Changed Description
CODED SITUATION (CLINICAL TERMINOLOGY)   Changed Description
FINDING DATE   Changed Description
OPCS-4 CODE   Changed Description
PROCEDURE (OPCS)   Changed Description
PROCEDURE (READ)   Changed Description
SEXUAL HEALTH AND HIV ACTIVITY PROCEDURE (SNOMED CT)   Changed Description
 

Date:23 October 2019
Sponsor:Nicholas Oughtibridge, Head of Clinical Data Architecture, NHS Digital

Note: New text is shown with a blue background. Deleted text is crossed out. Retired text is shown in grey. Within the Diagrams deleted classes and relationships are red, changed items are blue and new items are green.

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BIOPSY

Change to Supporting Information: Changed Description

A Biopsy is a Clinical Investigation.

A Biopsy is a medical procedure that involves taking a small sample of TISSUE for examination under a microscope.A Biopsy is a Patient Procedure that involves taking a small sample of TISSUE for examination under a microscope.

For further information on Biopsies, see the NHS website at: Biopsy.

 

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CLINICAL FINDING

Change to Supporting Information: New Supporting Information

A Clinical Finding is a CLINICAL INVESTIGATION RESULT ITEM.

A Clinical Finding represents the PATIENT DIAGNOSIS and symptoms of the PATIENT.

For example:

For further information on Clinical Findings, see the: SNOMED CT Fact Sheet.

 

This supporting information is also known by these names:
ContextAlias
shortnameFinding
pluralClinical Findings
indexnameFindings

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CLINICAL SITUATION

Change to Supporting Information: New Supporting Information

A Clinical Situation is a qualified PATIENT DIAGNOSISClinical Investigation or Patient Procedure.

A Clinical Situation represents a concept in which the clinical context is specified as part of the definition of the concept itself.

These include presence or absence of a condition, whether a Clinical Finding is current, in the past or relates to someone other than the subject of the record.

For example:

  • History of drug dependency
  • Family history: Myocardial infarction
  • Medication review done by Pharmacist.

For further information on Clinical Situations, see the: SNOMED CT Fact Sheet.

 

This supporting information is also known by these names:
ContextAlias
shortnameSituation
pluralClinical Situations
indexnameSituations

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INTENDED PATIENT PROCEDURE

Change to Supporting Information: Changed Description

An Intended Patient Procedure is PLANNED ACTIVITY.

An Intended Patient Procedure is a procedure intended to be performed on a PATIENT, recorded for an ELECTIVE ADMISSION LIST ENTRY, and classified by a CODED CLINICAL ENTRY.An Intended Patient Procedure is a is a Patient Procedure intended to be performed on a PATIENT, recorded for an ELECTIVE ADMISSION LIST ENTRY, and classified by a CODED CLINICAL ENTRY.

 

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OBSERVABLE ENTITY

Change to Supporting Information: Changed Description

An Observable Entity is a CLINICAL INTERVENTION.

An Observable Entity represents a question or assessment which can produce an answer or result, for example, SYSTOLIC BLOOD PRESSURE, color of iris etc.An Observable Entity represents a question or assessment which can produce an answer or result.

For further information on Observable Entities, see the SNOMED CT® Concept Model at: 6. SNOMED CT Concept Model: Observable entity.For example:

 
  • Colour of urine
  • Glomerular filtration rate.
  • For further information on Observable Entities, see the see the: SNOMED CT Fact Sheet.

     

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    PATIENT PROCEDURE

    Change to Supporting Information: Changed Description

    A Patient Procedure is a CLINICAL INTERVENTION.

    A Patient Procedure is a procedure performed on a PATIENT by a CARE PROFESSIONAL.

    A Patient Procedure may be carried out:

    • for the prevention, cure, relief or diagnosis of disease
    • during pregnancy
    • during childbirth.

    A Patient Procedure may be carried out as part of a Clinical Investigation, where it is both diagnostic and therapeutic, for example, certain endoscopic procedures.

     For further information on Patient Procedures, see the: SNOMED CT Fact Sheet.

     

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    ADDITIONAL UNPLANNED PROCEDURE REQUIRED INDICATOR

    Change to Attribute: Changed Description

    An indication of whether the PATIENT required an additional unplanned operation during the same Hospital Provider Spell as the primary procedure.An indication of whether the PATIENT required an additional unplanned operation during the same Hospital Provider Spell as the primary Patient Procedure.

    National Codes:

    YYes - the PATIENT required an additional unplanned operation
    NNo - the PATIENT did not require an additional unplanned operation
     

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    FINDING SCHEME IN USE

    Change to Attribute: Changed Description

    The type of CODED CLINICAL ENTRY used for the finding.The type of CODED CLINICAL ENTRY used for the Finding.

    National Codes:

    01ICD-10
    02Read Coded Clinical Terms Version 2
    03Read Coded Clinical Terms Version 3 (CTV3)
    04SNOMED CT®
     

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    SITUATION SCHEME IN USE

    Change to Attribute: Changed Description

    The type of CODED CLINICAL ENTRY used for the situation.The type of CODED CLINICAL ENTRY used for the Situation.

    National Codes:

    01ICD-10
    02Read Coded Clinical Terms Version 2
    03Read Coded Clinical Terms Version 3 (CTV3)
    04SNOMED CT®
     

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    ASSISTIVE TECHNOLOGY FINDING (SNOMED CT)

    Change to Data Element: Changed Description

    Format/Length:See SNOMED CT CODE
    National Codes: 
    Default Codes: 

    Notes:
    ASSISTIVE TECHNOLOGY FINDING (SNOMED CT) is the same as attribute CLINICAL TERMINOLOGY CODE.

    ASSISTIVE TECHNOLOGY FINDING (SNOMED CT) is the SNOMED CT® concept ID which is used to identify the finding relating to the Assistive Technology that a PERSON is dependent on.ASSISTIVE TECHNOLOGY FINDING (SNOMED CT) is the SNOMED CT® concept ID which is used to identify the Finding relating to the Assistive Technology that a PERSON is dependent on.

     

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    CODED FINDING (CODED CLINICAL ENTRY)

    Change to Data Element: Changed Description

    Format/Length:min an4 max an18
    National Codes: 
    Default Codes: 

    Notes:
    CODED FINDING (CODED CLINICAL ENTRY) is the same as attribute CLINICAL CLASSIFICATION CODE or CLINICAL TERMINOLOGY CODE.

    CODED FINDING (CODED CLINICAL ENTRY) is the CODED CLINICAL ENTRY which is used to identify a finding.CODED FINDING (CODED CLINICAL ENTRY) is the CODED CLINICAL ENTRY which is used to identify a Finding.

    For further information on findings, see the SNOMED CT® information at:For further information on Findings, see the SNOMED CT® information at: SNOMED CT Fact Sheet.

     

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    CODED OBSERVATION (CLINICAL TERMINOLOGY)

    Change to Data Element: Changed Description

    Format/Length:min an5 max an18
    National Codes: 
    Default Codes: 

    Notes:
    CODED OBSERVATION (CLINICAL TERMINOLOGY) is the same as attribute CLINICAL TERMINOLOGY CODE.

    CODED OBSERVATION (CLINICAL TERMINOLOGY) is the CLINICAL TERMINOLOGY CODE which is used to identify an observation.CODED OBSERVATION (CLINICAL TERMINOLOGY) is the CLINICAL TERMINOLOGY CODE which is used to identify an Observable Entity.

    For further information on observations, see the SNOMED CT® Glossary at: 2.4.5 Observable Entity.For further information on observations, see the see the: SNOMED CT Fact Sheet.

     

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    CODED PROCEDURE (CLINICAL TERMINOLOGY)

    Change to Data Element: Changed Description

    Format/Length:min an5 max an18
    National Codes: 
    Default Codes: 

    Notes:
    CODED PROCEDURE (CLINICAL TERMINOLOGY) is the same as attribute CLINICAL TERMINOLOGY CODE.

    CODED PROCEDURE (CLINICAL TERMINOLOGY) is the CLINICAL TERMINOLOGY CODE which is used to identify a Patient Procedure.

    For further information on Patient Procedures, see the SNOMED CT® information at: SNOMED CT Concept Model: Procedure.For further information on Patient Procedures, see the SNOMED CT Fact Sheet.

     

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    CODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY)

    Change to Data Element: Changed Description

    Format/Length:min an4 max an56
    National Codes: 
    Default Codes: 

    Notes:
    CODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY) is the same as attribute CLINICAL CLASSIFICATION CODE or CLINICAL TERMINOLOGY CODE.

    CODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY) is the CLINICAL CLASSIFICATION CODE or SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure.CODED PROCEDURE AND PROCEDURE STATUS (CODED CLINICAL ENTRY) is the CLINICAL CLASSIFICATION CODE or SNOMED CT EXPRESSION which is used to identify a Patient Procedure plus the status of the Patient Procedure.

     

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    CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT)

    Change to Data Element: Changed Description

    Format/Length:min an6 max an56
    National Codes: 
    Default Codes: 

    Notes:
    CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT) is the same as attribute CLINICAL TERMINOLOGY CODE.

    CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT) is the SNOMED CT EXPRESSION which is used to identify a procedure plus the status of the procedure.CODED PROCEDURE AND PROCEDURE STATUS (SNOMED CT) is the SNOMED CT EXPRESSION which is used to identify a Patient Procedure plus the status of the Patient Procedure.

     

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    CODED SITUATION (CLINICAL TERMINOLOGY)

    Change to Data Element: Changed Description

    Format/Length:min an4 max an18
    National Codes: 
    Default Codes: 

    Notes:
    CODED SITUATION (CLINICAL TERMINOLOGY) is the same as attribute CLINICAL TERMINOLOGY CODE.

    CODED SITUATION (CLINICAL TERMINOLOGY) is the CLINICAL TERMINOLOGY CODE which is used to identify the situation of a PERSON.

    For further information on situations, see the SNOMED CT® information at:For further information on Situations, see the SNOMED CT® information at:

     

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    FINDING DATE

    Change to Data Element: Changed Description

    Format/Length:an10 CCYY-MM-DD
    National Codes: 
    Default Codes: 

    Notes:
    FINDING DATE is the same as attribute PERSON PROPERTY RECORDED DATE.

    FINDING DATE is the date when the finding was recorded.FINDING DATE is the date when the Finding was recorded.

    For further information on findings, see the SNOMED CT® information at: Clinical finding.For further information on Findings, see the: SNOMED CT Fact Sheet.

     

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    OPCS-4 CODE

    Change to Data Element: Changed Description

    Format/Length:an4
    National Codes: 
    Default Codes: 

    Notes:
    OPCS-4 CODE is the same as attribute CLINICAL CLASSIFICATION CODE.

    OPCS-4 CODE is the OPCS Classification of Interventions and Procedures (OPCS-4) code which is used to identify the CODED CLINICAL ENTRY.

    Notes:

    • Where a procedure is carried out and required for reporting using the OPCS-4 classification, every effort must be made to report the appropriate OPCS-4 code in the Out-Patient Attendance Commissioning Data Set.
    • Where providers locally use OPCS-4 codes with a fifth character added, this should be removed before inclusion in the Commissioning Data Set.
    • Where a Patient Procedure is carried out and required for reporting using the OPCS-4 classification, every effort must be made to report the appropriate OPCS-4 code in the Out-Patient Attendance Commissioning Data Set.
    • Where providers locally use OPCS-4 codes with a fifth character added, this should be removed before inclusion in the Commissioning Data Set.
     

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    PROCEDURE (OPCS)

    Change to Data Element: Changed Description

    Format/Length:See OPCS-4 CODE
    National Codes: 
    Default Codes: 

    Notes:
    PROCEDURE (OPCS) is the same as attribute CLINICAL CLASSIFICATION CODE.

    PROCEDURE (OPCS) is a procedure other than the PRIMARY PROCEDURE (OPCS).PROCEDURE (OPCS) is a Patient Procedure other than the PRIMARY PROCEDURE (OPCS).

    For Commissioning Data Sets purposes it is recommended that multiple Procedures are recorded and the CDS XML Schema (CDS Version 6 onwards) has been designed to carry as many Procedures as required.For Commissioning Data Sets purposes it is recommended that multiple Patient Procedures are recorded and the CDS XML Schema (CDS Version 6 onwards) has been designed to carry as many Patient Procedures as required.

     

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    PROCEDURE (READ)

    Change to Data Element: Changed Description

    Format/Length:See READ CODE
    National Codes: 
    Default Codes: 

    Notes:
    PROCEDURE (READ) is the same as attribute CLINICAL TERMINOLOGY CODE.

    PROCEDURE (READ) is the Read Coded Clinical Terms for a procedure other than the PRIMARY PROCEDURE (READ).PROCEDURE (READ) is the Read Coded Clinical Terms for a Patient Procedure other than the PRIMARY PROCEDURE (READ).

    For Commissioning Data Sets purposes it is recommended that multiple Procedures are recorded and the CDS XML Schema (CDS Version 6 onwards) has been designed to carry as many Procedures as required.For Commissioning Data Sets purposes it is recommended that multiple Patient Procedures are recorded and the CDS XML Schema (CDS Version 6 onwards) has been designed to carry as many Patient Procedures as required.

    Note: Read Coded Clinical Terms Version 3 (CTV3) with qualifiers is not supported in the Commissioning Data Sets. Therefore, the Commissioning Data Set Version 6-2 XML Schema has the format of this Data Element constrained to max an5.

     

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    SEXUAL HEALTH AND HIV ACTIVITY PROCEDURE (SNOMED CT)

    Change to Data Element: Changed Description

    Format/Length:See SNOMED CT EXPRESSION
    National Codes: 
    Default Codes: 

    Notes:
    SEXUAL HEALTH AND HIV ACTIVITY PROCEDURE (SNOMED CT) is the same as attribute CLINICAL TERMINOLOGY CODE.

    SEXUAL HEALTH AND HIV ACTIVITY PROCEDURE (SNOMED CT) is the SNOMED CT EXPRESSION which is used to identify the procedure relating to the activity undertaken at an attendance for a Sexual Health Service.SEXUAL HEALTH AND HIV ACTIVITY PROCEDURE (SNOMED CT) is the SNOMED CT EXPRESSION which is used to identify the Patient Procedure relating to the ACTIVITY undertaken at an attendance for a Sexual Health Service.

    NOTE: SNOMED CT EXPRESSION constraint for procedure: (7138802 or <129152009)NOTE: SNOMED CT EXPRESSION constraint for Patient Procedure: (7138802 or <129152009).

     

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