# General Terminology Bindings

This section summarizes the key entities and attributes defined in the Logical Model and indicates where SNOMED CT concepts can be used to represent values.

{% hint style="info" %}
Additional attributes may be added as needed to support local or organizational requirements.
{% endhint %}

***

### Patient

| Attribute           | SNOMED CT Concept(s)                                                                                            | Description                                   | Notes                                                                                                        |
| ------------------- | --------------------------------------------------------------------------------------------------------------- | --------------------------------------------- | ------------------------------------------------------------------------------------------------------------ |
| **Name**            | << 703503000 \|Name (observable entity)\|                                                                       | The patient’s name                            | N/A                                                                                                          |
| **Age**             | 184099003 \|Date of birth (observable entity)\|or<< 424144002 \|Current chronological age (observable entity)\| | The patient’s age                             | N/A                                                                                                          |
| **Gender**          | 263495000 \|Gender (observable entity)\|or33821000087103 \|Gender identity (observable entity)\|                | The patient’s gender                          | < 285116001 \|Gender identity finding (finding)\|                                                            |
| **Medical History** | << 363788007 \|Clinical history/examination observable (observable entity)\|                                    | Records of past and ongoing health conditions | < 404684003 \|Clinical finding (finding)\|< 417662000 \|History of clinical finding in subject (situation)\| |

***

### Dietitian

| Attribute       | SNOMED CT Concept(s) | Description                                        | Notes                                                                                      |
| --------------- | -------------------- | -------------------------------------------------- | ------------------------------------------------------------------------------------------ |
| **Name**        | N/A                  | The dietitian’s full name                          | N/A                                                                                        |
| **Credentials** | N/A                  | Professional qualifications and certifications     | N/A                                                                                        |
| **Role**        | N/A                  | The specific function or position of the dietitian | < 159033005 \|Dietitian (occupation)\|< 223366009 \|Healthcare professional (occupation)\| |

***

### Nutrition Assessment

| Attribute                     | SNOMED CT Concept(s)                                                                                                                                              | Description                                         | Notes                                                                                                               |
| ----------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------------- | ------------------------------------------------------------------------------------------------------------------- |
| **Assessment Type**           | #**MEMBERS of the RefSet that are types of:** << 364393001 \|Nutritional observable (observable entity)\|or<< 225388007 \|Dietary intake assessment (procedure)\| | Type of assessment                                  | Model Meaning Binding                                                                                               |
| **Date**                      | 439272007 \|Date of procedure (observable entity)\|                                                                                                               | The date the assessment was conducted               |                                                                                                                     |
| **Food and Nutrition Intake** | #**MEMBERS of the RefSet that are types of:** << Clinical findings --> finding of nutr... intake                                                                  | Dietary intake information                          | < 300893006 \|Nutritional finding (finding)\|< 363246002 \|Nutritional deficiency associated condition (disorder)\| |
| **Anthropometrics**           | << 248326004 \|Body measure (observable entity)\|                                                                                                                 | Measurements like weight, height, and BMI           | 365605003 \|Body measurement finding (finding)\|                                                                    |
| **Lab Results**               | << 364712009 \|Laboratory test observable (observable entity)\|                                                                                                   | Results from laboratory tests relevant to nutrition | 441742003 \|Evaluation finding (finding)\|                                                                          |
| **Physical Findings**         | << 363788007 \|Clinical history/examination observable (observable entity)\|                                                                                      | Observable signs related to nutrition status        | < 404684003 \|Clinical finding (finding)\|                                                                          |

***

### Diagnosis

| Attribute          | SNOMED CT Concept(s)                                                                                      | Description                                         | Notes                                                                                                                                                                 |
| ------------------ | --------------------------------------------------------------------------------------------------------- | --------------------------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| **Diagnosis**      | 439401001 \|Diagnosis (observable entity)\|                                                               | Diagnosis label                                     | Model Meaning Binding                                                                                                                                                 |
| **Problem**        | << 439401001 \|Diagnosis (observable entity)\|                                                            | The nutrition issue identified (e.g., malnutrition) | ^ 1303957004 \|Nutrition Care Process Terminology reference set\| < 404684003 \|Clinical finding (finding)\|< 413350009 \|Finding with explicit context (situation)\| |
| **Etiology**       | [405534009 \|Adverse incident contributing factor (observable entity)\|](http://snomed.info/id/405534009) | The cause or contributing factor of the problem.    | 'Etiology value set'                                                                                                                                                  |
| **Signs/Symptoms** | N/A                                                                                                       | Observable or reported evidence of the problem.     | Can be used to represent clinical signs and symptoms. < [404684003 \|Clinical finding\|](http://snomed.info/id/404684003)                                             |

#### Etiology Value Set Example

| Etiology Domain           | SNOMED CT Concept(s)                                                                      | Description                                                                                                                 |
| ------------------------- | ----------------------------------------------------------------------------------------- | --------------------------------------------------------------------------------------------------------------------------- |
| **Beliefs–Attitudes**     | 118196009 \|Value belief finding (finding)\|                                              | Beliefs, emotional responses, or attitudes that impact nutrition (e.g., food aversion, denial, distrust of dietary advice). |
| **Cultural**              | N/A                                                                                       | Cultural values or customs influencing nutrition care.                                                                      |
| **Knowledge**             | 870752006 \|Finding related to health literacy (finding)\|                                | Lack of knowledge or health literacy affecting nutrition.                                                                   |
| **Physical Function**     | 105719004 \|Body disability AND/OR failure state (finding)\|                              | Physical or cognitive impairment limiting function.                                                                         |
| **Physiologic–Metabolic** | 404684003 \|Clinical finding (finding)\|                                                  | Medical factors such as disease or metabolic disorder.                                                                      |
| **Psychological**         | 284465006 \|Finding relating to psychosocial functioning (finding)\|                      | Mental health issues affecting nutrition care.                                                                              |
| **Social–Personal**       | 271437004 \|Problem situation relating to social and personal history\|                   | Social environment or personal history influences.                                                                          |
| **Treatment**             | N/A                                                                                       | Medical or surgical treatment affecting nutrition status.                                                                   |
| **Access**                | 445281000124101 \|Nutrition impaired due to limited access to healthful foods (finding)\| | Barriers to accessing safe or sufficient food.                                                                              |
| **Behavior**              | N/A                                                                                       | Behaviors contributing to nutritional problems.                                                                             |

***

### Diet Order

| Attribute         | SNOMED CT Concept(s)                                                                                                                              | Description                                                   | Notes                 |
| ----------------- | ------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------- | --------------------- |
| **Order**         | 16076005 \|Prescription (procedure)\|                                                                                                             | Represents the act of prescribing a diet                      | Model Meaning Binding |
| **Diet Type**     | << 278846007 \|Dietetic procedures (procedure)\|<< 386373004 \|Nutrition therapy (regime/therapy)\|                                               | Specific type of prescribed diet (e.g., diabetic, low sodium) |                       |
| **Modifications** | 445341000124100 \|Modification of nutritional regime (regime/therapy)\|<< 445341000124100 \|Modification of nutritional regime (regime/therapy)\| | Adjustments made to the diet (e.g., texture, volume)          |                       |

***

### Goal

| Attribute              | SNOMED CT Concept(s)                                   | Description                                 | Notes                                                                            |
| ---------------------- | ------------------------------------------------------ | ------------------------------------------- | -------------------------------------------------------------------------------- |
| **Goal**               | 225294001 \|Identifying goals (procedure)\|            | General goal-setting activity               | Model Meaning Binding                                                            |
| **Description**        | << 1055210001 \|Target parameter (observable entity)\| | Textual or coded representation of the goal | < 404684003 \|Clinical finding (finding)\|                                       |
| **Measurable Outcome** | << 1055210001 \|Target parameter (observable entity)\| | Quantifiable metric for evaluating progress | << 365605003 \|Body measurement finding (finding)\| (not limited to this subset) |
| **Target Date**        | N/A                                                    | Deadline for achieving the goal             | N/A                                                                              |

***

### Care Plan

| Attribute           | SNOMED CT Concept(s)                                           | Description                              | Notes                 |
| ------------------- | -------------------------------------------------------------- | ---------------------------------------- | --------------------- |
| **Plan Definition** | 1279742004 \|Development of nutrition care plan (procedure)\|  | Formal creation of a nutrition care plan | Model Meaning Binding |
| **Goals**           | << 1055210001 \|Target parameter (observable entity)\|         | High-level objectives in the care plan   | See Goal section      |
| **Start Date**      | N/A                                                            | Date the care plan starts                |                       |
| **End Date**        | 442137000 \|Completion time of procedure (observable entity)\| | Date the care plan ends                  |                       |

***

### Intervention

<table><thead><tr><th width="131.5546875">Attribute</th><th>SNOMED CT Concept(s)</th><th>Description</th><th>Notes</th></tr></thead><tbody><tr><td><strong>Type</strong></td><td>N/A</td><td>Type of intervention (e.g., education, supplementation)</td><td>^ 1303957004 |Nutrition Care Process Terminology reference set|&#x3C; 71388002 |Procedure (procedure)|</td></tr><tr><td><strong>Description</strong></td><td>N/A</td><td>Narrative or coded intervention detail</td><td>N/A</td></tr><tr><td><strong>Frequency</strong></td><td>N/A</td><td>How often the intervention is delivered</td><td>Can use FHIR timing data types</td></tr></tbody></table>

***

### Monitoring and Evaluation

| Attribute           | SNOMED CT Concept(s)                                                                                                                                              | Description                            | Notes                                    |
| ------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------- | -------------------------------------- | ---------------------------------------- |
| **Monitoring Type** | 386374005 \|Nutritional monitoring (regime/therapy)\|                                                                                                             | Follow-up or review action             | Model Meaning Binding                    |
| **Date**            | 439272007 \|Date of procedure (observable entity)\|                                                                                                               | Evaluation date                        |                                          |
| **Metrics**         | N/A                                                                                                                                                               | Metrics to track progress              | 404684003 \|Clinical finding (finding)\| |
| **Outcome**         | #**MEMBERS of the RefSet that are types of:** << 364393001 \|Nutritional observable (observable entity)\|or<< 225388007 \|Dietary intake assessment (procedure)\| | Final status or progress against goals |                                          |

<a href="https://docs.google.com/forms/d/e/1FAIpQLScTmbZIf0UEQwYDkY27EEWBkaiYkHSbR0_9DmFrMLXoQLyL7Q/viewform?usp=pp_url&#x26;entry.1767247133=NCPT+IG&#x26;entry.670899847=General%20Terminology%20Bindings" class="button primary">Provide Feedback</a>


---

# Agent Instructions: Querying This Documentation

If you need additional information that is not directly available in this page, you can query the documentation dynamically by asking a question.

Perform an HTTP GET request on the current page URL with the `ask` query parameter:

```
GET https://docs.snomed.org/implementation-guides/ncpt-implementation-guide/5-information-models-and-terminology-binding/5.3-general-terminology-bindings.md?ask=<question>
```

The question should be specific, self-contained, and written in natural language.
The response will contain a direct answer to the question and relevant excerpts and sources from the documentation.

Use this mechanism when the answer is not explicitly present in the current page, you need clarification or additional context, or you want to retrieve related documentation sections.