Procedure with Explicit Context

Definition and Purpose

Procedures with explicit context describe situations where a medical procedure’s status, timing, or relationship to the patient is specified. These concepts clarify whether a procedure is planned, completed, or not done, among other statuses.

Attributes Used

• Associated Procedure: Links the situation to the specific procedure being considered.

  • For example, |Lung transplant planned (situation)| uses this attribute to connect to |Lung transplant (procedure)|.

• Procedure Context: Describes the status of the procedure, such as whether it is planned, completed, or not done.

  • For example, |Lung transplant planned (situation)|, the procedure context is |Planned|.

• Temporal Context: Indicates when the procedure is or was to take place (past, present, future).

  • For example, |Lung transplant planned (situation)| uses |In the future| as the temporal context.

• Subject Relationship Context: Specifies who the procedure pertains to, usually the patient but can be a different person.

  • For example, |Mother’s surgery planned (situation)| would indicate the procedure pertains to the patient’s mother.

The default values for the context attributes for procedures assume that the procedure has occurred, is current or at a specified time, and pertains to the subject of the record.

Associated Procedure

Awaiting transplantation of kidney

The SNOMED CT concept 698306007 |Awaiting transplantation of kidney (situation)| describes a patient’s status as they await a kidney transplant. A key attribute here is 363589002 |Associated procedure (attribute)| Associated procedure, which is 70536003 |Transplant of kidney (procedure)| . This indicates that the focus of the situation is the upcoming kidney transplantation procedure. Additionally, the concept includes the |Procedure context (attribute)| as |To be done (qualifier value)| To be done, specifying that the transplant is planned but not yet performed, and it applies to the patient at the |Current or specified time (qualifier value)| .

Examples - Procedure Context

Lung transplant planned (situation)

The SNOMED CT concept 704202004 |Lung transplant planned (situation)| represents a planned lung transplant for a patient. A key attribute here is |Procedure context (attribute)| 397943006 |Planned (qualifier value)| . This attribute indicates that the lung transplant is scheduled for the future and has not yet been performed. Additionally, the concept includes |Associated procedure (attribute)| as |Transplant of lung (procedure)|

, specifying the type of procedure planned. The |Subject relationship context (attribute)|

is |Subject of record (person)| , indicating that the procedure pertains to the patient themselves. The |Temporal context (attribute)| is |Current or specified time (qualifier value)| , showing that the procedure is relevant at the present time or based on a specific schedule.

Examples - Subject Relationship Context

Family history of mastectomy (situation)

The SNOMED CT concept 433977002 |Family history of mastectomy (situation)| represents the occurrence of mastectomy within a patient’s family history. A key attribute here is Subject relationship context, which is 303071001 |Person in the family (person)| . This attribute specifies that the mastectomy is related to a family member rather than the patient themselves. The concept also includes the associated procedure as |Excision of breast (procedure)| , indicating that the mastectomy was the specific procedure performed, and the procedure context as Done, reflecting that the procedure has been completed. The temporal context is |Current or past (actual) (qualifier value)| , signifying that the procedure occurred in the past or is relevant at present.

Examples - Temporal Context

The SNOMED CT concept 134651000119108 |History of estrogen therapy (situation)| details a patient’s past use of estrogen hormone therapy. A key attribute here is |Temporal context (attribute)| , which is 410513005 |In the past (qualifier value)| . This attribute specifies that the estrogen therapy occurred in the past. Additionally, the concept includes |Associated procedure (attribute)| as |Estrogen hormone therapy (procedure)| , indicating the specific therapy administered, and |Procedure context (attribute)| as |Done (qualifier value)| , showing that the therapy was completed. The subject relationship context is |Subject relationship context (attribute)| as |Subject of record (person)| , signifying that the therapy pertains to the patient themselves.