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.

A Clinical Finding is a CLINICAL INVESTIGATION RESULT ITEM.

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

For example:

• Asthma (disorder)
• Headache (Finding)
• Normal breath sounds (Finding)
• Tired all the time (Finding).

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

This supporting information is also known by these names:

Context	Alias
shortname	Finding
plural	Clinical Findings
indexname	Findings

A Clinical Situation is a qualified PATIENT DIAGNOSIS, Clinical 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:

Context	Alias
shortname	Situation
plural	Clinical Situations
indexname	Situations

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.

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:

For further information on Observable Entities, see the see the: SNOMED CT Fact Sheet.

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.

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:

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

National Codes:

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

National Codes:

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.

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.

• Clinical finding
• SNOMED CT Concept Model: Clinical finding.

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.

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.

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.

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.

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:

• Glossary: Situation with explicit context
• Glossary: clinical situation
• SNOMED CT Concept Model: Situation with explicit context.
• SNOMED CT Fact Sheet.

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.

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.

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.

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.

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).