At the point of care, search is done in order to find a Concept which describes a specific event that occurred during the course of patient care (e.g. documenting the findings related to a physical examination, diagnosis or surgical procedure into a form).
Data entry forms in clinical records are often designed for a specific documentation purpose. Designing the interface of a data entry forms and/or its content may entail associating Concepts with a template element or control. In highly structured forms, the design may involve specifying what Concepts should be available for selection. In less structured templates, the design may involve specifying the features useful for conducting an efficient and effective search. Thus, template designers may need to be able to search the whole terminology but also have the competencies to manually constrain the search by various filters and applying advanced functionalities, such as expression views and comparison between Concepts.
For more information on structured data entry, please refer to the "" sub-section.
Searching for a Concept can satisfy a wide range of use cases. This section describes common use cases that require effective search techniques. Each of these use cases may require a different combination of search techniques. The first sub-section describes SNOMED CT within the context of a clinical record application which is directly connected to data entry, and the second sub-section describes the use of SNOMED CT within a browser.
Search can be required for defining Concepts and Descriptions that are used in subsequent data retrieval from patient records. The effectiveness of a search technique depends on the requirements for reporting and analysis (e.g. creating a query that searches for SNOMED CT coded data within specific subtype-hierarchies).
The integration of clinical decision support tools into clinical record systems can help to improve evidence-based practice. The binding of SNOMED CT to knowledge artifacts enables the linkage between the knowledge content in clinical decision support and the SNOMED CT coded data items in the clinical record. The binding typically entails searching for the SNOMED CT Concept. Effective techniques for searching for SNOMED CT Concepts for data entry can improve the assessment of the context of a Concept within SNOMED CT prior to binding and the overall binding efficiency.
For example to review content coverage
There can be various use cases for reviewing SNOMED CT content. For example, terminology content can be evaluated to decide whether the coverage of SNOMED CT is a sufficient to fit documentation purposes (e.g. a cardiovascular surgeon could assess whether SNOMED CT covers all cardiovascular terms). This assessment typically entails searching for SNOMED CT Concepts which requires effective search techniques.
In mapping, searching to identify SNOMED CT Concepts required to be mapped to or from another code scheme (e.g. ICD-10 or local codes) is required.
For example to represent subsets of terms and concepts
Identifying subsets of Concepts or Descriptions for inclusion in a Reference Set typically requires searching SNOMED CT content.
Realizing and understanding the comprehensiveness and complexity of SNOMED CT may be a steep learning curve for users. Searching and browsing through navigational results can aid the learning process. Thus, effective search techniques increase the chances of finding the required content and understanding where it fits into the overall structure of SNOMED CT.
Terminology authorities such as National Release Centers may need to edit SNOMED CT Descriptions to adhere to national or local linguistic/editorial guidelines. This entails searching large subsets of Concepts and Descriptions. Thus, effective search techniques are required to find the correct Concept or Description within these large subsets.