Since the skeletal system includes bones and cartilage, it is possible to have a procedure on the skeletal system, i.e. on cartilage, that is not a procedure on bone.

• For example,

  • 77825002 |Division of cartilage of wrist (procedure)| is a procedure on the skeletal system (procedure)

Osteotomy

Osteotomy is defined as cutting into or through a bone; there are 3 meanings in SNOMED CT:

1. Cutting into a bone, regardless of whether the bone is divided (incision, general meaning). Model using Method, Incision - action (qualifier value), and Procedure site - Direct (attribute), bone structure (or subtypes).

   1. For example,

      1. 118483001 |Incision of rib (procedure)|

2. Cutting through a bone and dividing it (division by cutting). Model using Method, Division - action (qualifier value), and Procedure site - Direct (attribute), bone structure (or subtypes).

   1. For example,

      1. 447867002 |Division of ulna (procedure)|

3. Cutting into a bone without cutting through it and therefore without dividing it (incision without division).

   1. This is unnecessary; procedures that do not explicitly involve division are modeled simply as Incision.

Reduction and fixation has two actions by two different means; open reduction of a fracture and insertion of an orthopedic fixation device. This provides an opportunity for general concept inclusion axioms (GCIs) in order to fully represent the meanings without heavy postcoordination modeling. Open reduction of a fracture necessarily involves open manipulation of the fracture and internal fixation of a fracture necessarily involves the insertion of an orthopedic internal fixation device.

• For example,

  • 74011006 |Open reduction of fracture of tibia and fibula with internal fixation (procedure)|

The concept model for flap procedures is based on three attributes in a role group as outlined below:

363701004 |Direct substance (attribute)|

• 363701004 |Direct substance (attribute)| must have a value from the 256683004 |Flap (substance)| subhierarchy, and indicate the direct flap substance composition, and its blood supply.

• 363701004 |Direct substance (attribute)| must be used for flap procedures (and not 424361007 |Using substance (attribute)|).

• Flap substances exist for free flaps and pedicle flaps (<<261238005 |Free flap (substance)| and << 261235008 |Pedicle flap (substance)|) and reflect the fact that whether a flap is free or pedicle is also a function of its blood supply (i.e. completely unattached from its original blood supply, or still attached via a vascular pedicle).

• Also see .

• For flap reconstruction procedure, 260686004 |Method (attribute)| must have a value from the 360032005 |Flap reconstruction - action (qualifier value)| subhierarchy and indicate the flap procedure technique, for example, advancement or rotation of flap.

• For free flap procedures, the method is 1193839003 |Distant flap reconstruction - action (qualifier value)|

• The proximity of the flap donor site to the flap recipient site (local flap/distant flap) must be modeled as part of the methodology of the procedure (and is no longer a characteristic of the flap substance).

• If it is known where on the body the procedure to perform the flap reconstruction, or flap creation, or other flap procedure is performed, then 405813007 |Procedure site - Direct (attribute)| is used (do not use 405814001 |Procedure site - Indirect (attribute)|).

• Do not include 405813007 |Procedure site - Direct (attribute)| if no location on the body is specified.

• Do not include general value 442083009 |Anatomical or acquired body structure (body structure)| if no body site is stated.

• FSN: Reconstruction using flap (procedure)

• PT: Reconstruction using flap

• SYN: Reconstruction with flap

• SYN: Flap reconstruction [optional]

• FSN: Reconstruction of x body structure using y flap (procedure)

• PT: Reconstruction of x body structure using y flap

• SYN: Reconstruction of x body structure with y flap

• SYN: y flap reconstruction of x body structure [optional]

When authoring in this domain, these are the approved attributes and allowable ranges.

386053000 | Evaluation procedure (procedure)| has unique defining attributes as seen in its separate table below.

See also respective Templates.

Domain Information for Procedure

Modeling new content requests

Requests for new imaging-related content must clearly specify an imaging action; for example, computed tomography, plain X-ray, fluoroscopy, etc.

Radiographic imaging is a broad term that encompasses several types of imaging studies that use ionizing radiation for visualization of internal parts of the body using X-ray techniques (for example, computed tomography) and is therefore a grouping concept. New content requests using the phrase Radiographic imaging of and/or submissions requesting a Method (attribute) of 278110001 |Radiographic imaging - action (qualifier value)| are not acceptable for the international edition of SNOMED CT.

Approved naming pattern

FSN: Plain X-ray of (procedure) PT: Plain X-ray of

The X is capitalized, and the description case sensitivity is Only initial character case insensitive.

The following are acceptable synonyms:

• Plain film of X

• Plain radiography of X

The terms radiologic and radiologic guidance are not permitted for any new descriptions, neither FSN nor synonyms. Neither are the following patterns permitted for any new descriptions:

• Radiography of X

  • For example,

    • Radiography of hand (procedure)

• X-ray of X

363680008 | Radiographic imaging procedure (procedure)| is at the top-level of the hierarchy of imaging procedures utilizing ionizing radiation for X-ray techniques. This concept has been retained along with a small number of high usage subtypes that are modeled with method 278110001 |Radiographic imaging - action (qualifier value)|.

FSN: Dual energy X-ray absorptiometry of X (procedure)

PT: Dual energy X-ray absorptiometry of X

SYN: DXA of X

SYN: DEXA of X

• For example,

  • 428313006 | Dual energy X-ray absorptiometry of mandible (procedure)|

    • FSN: Dual energy X-ray absorptiometry of mandible (procedure)

    • PT: Dual energy X-ray absorptiometry of mandible

Division and lysis

Division - action (qualifier value) is a subtype of Incision - action (qualifier value). This does not mean that all procedures, that include the word division, should necessarily be modeled with Method (attribute) of Division - action (qualifier value), like those where the division is accomplished using blunt dissection, not incision.

• For example,

  • Division of adhesion concepts, like 173269002 |Division of adhesions of lip (procedure)|, should be modeled the same as lysis of adhesion concepts, like 45602008 |Lysis of adhesions of peritoneum (procedure)|

Both use Dissection - action (qualifier value). Adhesions are broken down by blunt dissection, often without incising them. This does not exclude procedures that may also involve division by incision.

The preferred name of division of adhesions concepts can be changed to lysis of adhesions for consistency. The use of lysis of adhesions also helps with correct modeling and avoidance of interpreting divisions as necessarily being kinds of incision.

Transection is defined as a division across the longitudinal axis of a structure by cutting. Bisection is defined as division into two parts by cutting. Transection - action (qualifier value) is a subtype of Bisection - action (qualifier value), which is a subtype of Division - action (qualifier value) and Incision - action (qualifier value).

• For example,

  • 53176004 |Transection of muscle of eye (procedure)|

  • 60158005 |Bilateral bisection of ovary (procedure)|

Procedure concepts

Procedure concepts represent activities performed in the provision of health care. This hierarchy represents a broad variety of activities, including but not limited to:

• Invasive procedures, e.g., 77018005 |Excision of lesion of intracranial artery (procedure)|

• Administration of medicines, e.g., 39343008 |Pertussis vaccination (procedure)|

• Imaging procedures, e.g., 47079000 |Ultrasonography of breast (procedure)|

• Education procedures, e.g., 183063000 |Low salt diet education (procedure)|

• Administrative procedures, e.g., 305212007 |Medical records transfer (procedure)|

Concepts which describe adjacent structures, imaged in one procedure, are acceptable.

For example,

• 432672003 | Magnetic resonance imaging of pelvis and hip (procedure)|

There is no need to distinguish between endoscopy and endoscopic procedure, as the procedure always includes inspection and may require minor incisions to allow the endoscope and other instruments to be inserted, or insertion may be via an existing orifice.

In all endoscopic procedures, a role group with Method of Inspection - action (qualifier value) + Using Device is mandatory. For endoscopies that require an incision, the role group to represent the incision is required. Where an additional action is performed during an endoscopy, a third role group is modeled with the applicable action.

Endoscopy/Endoscopic procedure modeling

Inspection only via natural orifice = 1 role group with Inspection

Role group:

• Method = Inspection

• <<Procedure site = <body structure>

• Using device = <physical object>

For example

Role group 1:

• Method = Inspection

• <<Procedure site = <body structure>

• Using device = <physical object>

Role group 2:

• Method = <action qualifier value>

• <<Procedure site = <body structure>

For example

Role group 1:

• Method = Inspection

• <<Procedure site = <body structure>

• Using device = <physical object>

Role group 2:

• Method = Incision

• Procedure site - Direct = <body structure>

For example

Role group 1:

• Method = Inspection

• <<Procedure site = <body structure>

• Using device = <physical object>

Role group 2:

• Method = Incision

• Procedure site - Direct = <body structure>

Role group 3:

• Method = <action qualifier value>

• <<Procedure site = <body structure>

For example

Endoscopes are complex pieces of equipment that support much more than just the act of visualization. However, one does not usually use the scope to access the site of the intended inspection or therapeutic procedure.

USING DEVICE: When an incision RG is included in the concept model then the correct attribute for the device is USING DEVICE. For example, access to the abdominal cavity, or a joint capsule, is achieved by an ordinary incision using a scalpel blade. The laparoscope or arthroscope is then introduced into the cavity through the incision i.e. the endoscope is not the access device.

USING ACCESS DEVICE: Many procedures can be carried out using tools attached to or operated via channels within the endoscope. In some cases the device IS used for access (such as endoscopy of the GI tract), e.g. ERCP in particular allows you to both visualize and operate upon the sphincter of Oddi/ampulla of Vater using cutting devices (knives or wires etc.) and then passing a basket up into the CBD to remove stones. The correct attribute for the device is USING ACCESS DEVICE.

Laparoscopy and laparoscopic procedure are synonymous. These procedures are modeled with at least two role groups:

• Role group:

  • Method = Incision - action (qualifier value)

  • Procedure site - Direct = Anterior abdominal wall structure (body structure)

• Role group:

<< 1288025000 | Prosthetic arthroplasty of joint (procedure)|

Prosthetic arthroplasties refer to the partial or total replacement of bones of a joint with a prosthetic device. All prosthetic arthroplasty concepts must be modeled with a Repair role group to ensure they classify under 442095009 |Repair of joint (procedure)|, along with an Implantation role group for the prosthetic device.

Total joint replacement

Total joint procedures are modeled by repair and implantation role groups. The repair group must have the 405813007 | Procedure site - Direct (attribute)| value of the entire joint. In the implantation role group, as the prostheses are applied to all of the bones in a joint, the generic joint prosthesis and joint structure concepts should be used in modeling to subsume hybrid total arthroplasties.

Cemented total arthroplasty

The use of bone cement should only be included in the implantation role group. The entire joint in the repair group represents the totality of arthroplasty, as does the total joint prosthesis in the implantation role group.

Hybrid total arthroplasty

Bone cement is only applied to one bone in a joint, leaving the other bone uncemented. Hence, a hybrid total arthroplasty should not be a subconcept of a cemented total arthroplasty.

If the cemented component is unspecified, the single implementation role group follows the model of total joint replacements with an additional substance of bone cement.

If the cemented component is known, multiple implantation role groups should be created to represent the prosthesis component of each bone.

It may be important, from both clinical and administrative perspectives, to capture variations or modifications of imaging technique. The variations may impact correct acquisition and interpretation of images.

• Examples of modifications include:

  • Axial (qualifier value)

  • Skyline projection (qualifier value)

The following contain the defining attributes for Procedure concepts. Evaluation procedures have unique defining attributes.

Provide Feedback

Although the use of terminology may vary across specialties, in general, grafting is where tissue is completely separated from its source of origin or donor, without its own blood supply, then affixed to a recipient site. The recipient site provides the vascularity.

Graft of skin is

• A section of skin with variable size, thickness, and origin

• Completely detached from its original site and moved to cover the area to be repaired without the benefit of any blood supply

For grafting, the recipient site is represented with the Procedure site - Direct (attribute), and the graft is represented with the Direct substance (attribute).

Fixation or attachment of tissue involves skin, bone, cartilage, or fat, rather than whole organs. The term can also be used for fixation or attachment of synthetic materials (e.g., a bioengineered skin graft is a manufactured skin graft grown in the laboratory from the patient's own cells, other allogeneic or xenogeneic sources, and/or synthetic materials; for example, silicone graft).

For example,

• 783285007 |Full thickness graft of skin to skin of neck (procedure)|

  • Proximal primitive Is a (attribute) value is 71388002 Procedure (procedure)

  • A single relationship group consists of:

    • 260686004 |Method (attribute)| = 129407005 |Grafting - action (qualifier value)|

An encounter is defined as an in-person meeting between a patient and a healthcare provider for the purpose of the provision of healthcare services to the patient. 308335008 |Patient encounter procedure (procedure)| is a subtype of Procedure (procedure).

For example,

• 185349003 |Encounter for check up (procedure)|

An indirect encounter occurs without a face-to-face meeting. 185316007 |Indirect encounter (procedure)| is a subtype of 308335008 |Patient encounter procedure (procedure)|.

For example,

The term Diathermy has been used to refer to a broad array of procedures aimed at performing different types of actions and outcomes. In SNOMED CT, the term diathermy may refer to 3 different kinds of procedures:

Therapeutic diathermy:

1. A treatment that provides deep heat to the tissues without destructive action.

• Therapeutic application of conductive heat using heated pads, water, or other materials to promote healing.

• Employment of physical agents that convert high-frequency electric current or electromagnetic waves to deep heat to promote healing.

Surgical diathermy:

2. The use of energy to destroy tissue for different purposes.

• A procedure in which tissue is heated to destroy abnormal cells. The heat may be using different types of energy.

3. The use of heat as a destructive procedure to perform a "secondary" action. e.g. Reattachment, repair.

Careful review of the intention of a procedure stating the term diathermy in the descriptions should be done. The term diathermy may be used to name non-destructive procedures. Before naming and modeling such concepts, be sure to carefully read this guide and the associated templates.

Destructive procedure performed by applying electrical energy to heat biological tissues. The term Surgical Diathermy refers to different types of surgical actions performed using electricity (e.g., electrocauterization, electrocoagulation, electrodesiccation). To consistently name the different types of actions and to accurately differentiate them, the descriptions must be based on the specific action stated in the description and secondarily on the term diathermy.

When a specific destructive action (cauterization, coagulation, desiccation) is stated in descriptions, use that action in the FSN for the concept and avoid the inclusion of the term Diathermy. Additionally, add "using electrical energy" to the FSN. The use of the prefix "electro-" to describe a destructive action using electricity is no longer required in the FSN but will be retained on concepts as Preferred or Acceptable description in concepts where such a description was previously used, for searchability and retrieval.

FSN: [Action] of [morphologic abnormality] of [body structure] using electrical energy (procedure)

• For example,

  • 232597008 |Bronchoscopic cauterization of lesion using electrical energy (procedure)|

PT: [Action] of [morphologic abnormality] of [body structure] using electrical energy

• For example,

  • Cauterization of lesion of vagina using electrical energy (procedure)

SYN: Electro-[Action] of [morphologic abnormality] of [body structure]

• For example,

  • Electrocauterisation of urinary bladder

If a specific non-destructive action (e.g., repair, reattachment) is included in the FSN along with the term diathermy, the descriptions should follow the pattern below:

FSN: [Action] of [morphologic abnormality] of [body structure] by diathermy (procedure)

• For example,

  • 57103007 |Reattachment of retina by diathermy (procedure)|

PT: [Action] of [morphologic abnormality] of [body structure] by diathermy

• For example,

  • Repair of retinal tear or defect by diathermy

When the FSN states the phrase, “Diathermy of X”, without any other considerations, a destructive action using Electrical energy should be inferred. In these cases, using the term Diathermy is allowed in the FSN and PT given that the specific action (e.g. coagulation, cauterization, etc.) is not stated. The destructive action (named Surgical diathermy) may be applied to a Morphologic abnormality or to a Body structure.

Before modeling this type of concept, make sure that the concept is not referring to Therapeutic diathermy (regime/therapy) (e.g. Microwave therapy), if the concept is not a destructive but therapeutic diathermy procedure, please refer to Therapeutic diathermy below.

FSN: Diathermy of [morphologic abnormality] of [body structure] (procedure)

• For example,

  • 301876002 |Diathermy of wart (procedure)|

PT: Diathermy of [morphologic abnormality] of [body structure]

• For example,

  • Diathermy of fallopian tube

Diathermy used for non-surgical/non-destructive procedures, e.g. physical therapy and chiropractics. To avoid confusion between surgical and non-surgical diathermy procedures, Therapeutic diathermy procedures should be described including the energy used in the procedure, and must be stated on the FSN. These procedures are subsumed by 91251008 |Physical therapy procedure (regime/therapy)|.

Use the name of the energy used in the procedure (e.g., microwave, conductive heat, shortwave) followed by the term diathermy, then "to", and finally the "Anatomical or acquired body structure" where the procedure is applied.

FSN: [Physical force] diathermy to [body structure] (regime/therapy)

PT: [Physical force] diathermy to [body structure]

• For example,

  • 306876003 |Microwave diathermy to lower limb (regime/therapy)|

  • 304394001 |Short wave diathermy to neck (regime/therapy)|

  • 49913004 |Ultrashort wave diathermy (regime/therapy)|

When the specific surgical action ("by coagulation", "by cauterization") is stated, but there is neither any mention of the type of physical force used nor the term diathermy stated in the descriptions, the concept should not be considered a diathermy procedure. Do not use any prefix or the term diathermy in descriptions.

These types of procedures should be classified in other hierarchies, e.g. Cauterization procedure (procedure), Coagulation procedure (coagulation).

FSN: [Action] of [morphologic abnormality] of [body structure] (procedure)

PT: [Action] of [morphologic abnormality] of [body structure] (procedure)

FSN: [Action] of [morphologic abnormality] of [body structure] by [Action] (procedure)

PT: [Action] of [morphologic abnormality] of [body structure] by [Action] (procedure)

• For example,

  • 56121000 |Repair of arteriovenous fistula by coagulation (procedure)|

  • 1287542001 |Coagulation of external ear (procedure)|

  • 15593007 |Cauterization

The definition of surgical repair is restoring, to the extent possible, an anatomical structure, using a surgical action. Repair is an objective or intended accomplishment, not a means (e.g., suturing, transplanting, etc.) nor a need (e.g., normal functioning, cosmetic appearance, pain relief, etc.).

Surgery that restores structure is usually intended to restore function and appearance. Restoring function, however, is not necessary for a procedure to be considered a repair. It is also possible for surgery to restore function without restoring structure (e.g., surgery to attach a prosthetic limb after amputation). This type of surgery would not be strictly categorized as a repair.

The Method (attribute) is used to model both the objective of a procedure and the means used to accomplish it. If a procedure requires both a repair action and another type of action, then two relationship groups should be used.

Fistula

Closure action is a kind of repair action. All fistula closures use the closure action and are classified as kinds of repair procedures.

• For example,

  • 79433000 |Closure of colon fistula (procedure)| has Method (attribute), Closure - action (qualifier value) with a parent, Repair of colon (procedure)

Surgery that accomplishes a repair (a structural restoration) often uses the suffix -plasty. The term plastic repair is also used. In order to avoid redundancy, the following terms are used:

• Prosthetic repair, using external (non-body) materials

• Plastic repair, reshaping the body

Almost all imaging procedures can be unambiguously expressed in a number of ways. There is a balance between flexibility in language and efficiency in terminology maintenance. Consequently, all variants for imaging modalities are not routinely included in SNOMED CT. Submissions for additional descriptions must be justified explicitly.

At a minimum, procedures are ordinarily expressed with the modality and body site. Existing content may have inconsistencies, but new content should following the naming conventions that follow.

When an imaging procedure involves visualization of a device and/or a morphologic abnormality in addition to an anatomic site, all of these are direct objects of imaging and therefore are represented using Direct morphology, Direct device, and Procedure site Direct attributes.

For example,

There are very few imaging procedures which are truly multi-modality procedures. Two procedures are usually conducted in parallel, rather than as one. Positron emission tomography with computed tomography (PET/CT) and Single photon emission computed tomography with computed tomography (SPECT/CT), however, are produced by one piece of equipment, possibly by a single technician, but with multiple imaging energies.

Positron emission tomography with computed tomography

• FSN: Positron emission tomography with computed tomography of X (procedure)

• PT: PET CT of X

• SYN: Positron emission tomography with computed tomography of X

  • For example,

    • 16554361000119106 | Positron emission tomography with computed tomography of brain (procedure)|

      • FSN: Positron emission tomography with computed tomography of brain (procedure)

      • PT: PET CT of brain

• FSN: Single photon emission computed tomography with computed tomography of X (procedure)

• PT: Single photon emission computed tomography with computed tomography of X

• SYN: SPECT CT of X

  • For example,

A revision procedure may or may not be a subtype of the original procedure. Revision procedure concepts should be in the 118635009 |Revision (procedure)| subhierarchy.

• For example,

  • 171839006 |Re-release of carpal tunnel (procedure)| is modeled as follows:

Duplex ultrasonography, Doppler ultrasound, and Doppler ultrasonography procedures were previously modeled with the Using device (attribute) with a value of 43770009 |Doppler device (physical object)| and a Method (attribute) of 278292003 |Ultrasound imaging - action (qualifier value)| or 302204005 |Ultrasound - action (qualifier value)|. It was not possible to sufficiently model duplex procedures to make them distinct from Doppler scans, and modeling of Doppler procedures was inconsistent with other imaging procedures where the modality was represented in the Method.

The concept model is now updated to be consistent with other imaging procedures. The Using device (attribute) has been removed, and the respective imaging modality has been added as a value for the Method (attribute), i.e. |Doppler ultrasound imaging - action (qualifier value)| and |Duplex ultrasound (qualifier value)|.

Doppler ultrasonography of x (procedure)

• For example,

Aspiration is extraction using negative pressure. When modeling aspiration concepts, procedure site distinction is made if the removal is either (1) a substance from within a body structure or specific morphology, or (2) removal of any of the body structure itself (including cells).

1. Removing a substance from within a body structure or specific morphology should be modeled using Procedure site - Indirect (attribute) and/or Indirect morphology (attribute).

   1. For example,

      1. Paracentesis of skin (procedure) is removing a substance from within the body structure and not the body structure itself, it is modeled using Procedure site - Indirect (attribute) of Skin structure.

2. Removing body structure cells should be modeled with Procedure site - Direct (attribute) and/or Direct morphology (attribute).

   1. For example,

      1. Fine needle aspiration biopsy of skin (procedure) removes part of the body structure itself, and therefore is modeled using Procedure site - Direct (attribute) of Skin structure.

The nature of some aspirations means the procedure site will inherently be modeled as either direct or indirect regardless of whether the FSN states a substance is being removed.

• Example procedures using Procedure site - Direct (attribute):

  • Fine needle aspiration biopsy

  • Bone marrow aspiration

  • Suction assisted lipectomy/Liposuction

If the substance being aspirated is not stated in the FSN, do not model it, even if it might be implied.

• Exception: Aspiration of abscess can use Direct substance = Pus (substance).

  • Abscesses can be either septic (due to infection) or sterile (not due to infection). Most abscesses are septic; however, pus is characteristic of an abscess - whether septic or sterile. Model with Indirect morphology (attribute) of Abscess (morphologic abnormality) and the Direct substance (attribute) of Pus (substance). Pus does not have to be stated in the FSN.

Procedure concepts with a body structure that has a left/right side

When creating a lateralized procedure concept, two concepts should be created:

1. concept for the left side

2. concept for the right side

When creating a lateralized procedure concept, if a non-lateralized parent does not exist, then it should be created as well. In other words, do not just create the right and left versions, but also create a concept to represent the laterality-agnostic parent.

• For example,

  • When creating |Excision of left mastoid| and |Excision of right mastoid|, ensure a concept for |Excision of mastoid| exists.

The acceptable naming pattern for procedures with lateralizable body parts:

• FSN: <Method> of bilateral <body structures> (procedure)

• PT: <Method> of bilateral <body structures>

• SYN: <Method> of both <body structures>

Bilateral procedures should be modeled using two relationship groups, one for each lateralized body structure.

• For example,

  • 895470004 |Amputation of bilateral upper limbs (procedure)|

    • FSN: Amputation of bilateral upper limbs (procedure)

    • PT: Amputation of bilateral upper limbs

The following defining attributes are unique in the context of the 386053000 |Evaluation procedure (procedure)| subhierarchy. Many of these attributes (e.g., Component, Scale type) are used to define Observable entity concepts. Evaluation procedures may use the attributes below in addition to those attributes allotted to the 71388002 | Procedure (procedure)| hierarchy (see Procedure Attributes Summary). Attributes for Evaluation procedure concepts are grouped. The future of this hierarchy in relation to the observable entity hierarchy is under review. See 'Observable Entity vs. Evaluation Procedure' at Observable Entity.

Component

Component refers to what is being observed or measured by a procedure.

For example,

• 442091000 | Measurement of ethanol using gas chromatography (procedure)| has 246093002 | Component (attribute)| of 419442005 | Ethanol (substance)|

Although Pharmaceutical / biologic product (product) and its descendants are considered valid values for the Component (attribute), they are not currently used as values for this attribute in the International Release. The only exception is 787859002 |Vaccine product (medicinal product)| and its descendants, which are used as valid values for this attribute.

Has Specimen indicates the type of specimen on which a measurement or observation is performed.

For example,

• 442165003 | Quantitative measurement of polychlorinated biphenyl in blood specimen using gas chromatography (procedure)| uses 116686009 | Has specimen (attribute)| of 119297000 | Blood specimen (specimen)|

Measurement Method specifies the method by which an evaluation procedure is performed. It provides additional specificity. For measurement procedures, the 260686004 | Method (attribute)| is given the value 129266000 | Measurement - action (qualifier value)| . No concept can be defined with a 370129005 | Measurement method (attribute)| unless it is being used to refine a 260686004 | Method (attribute)| that has a value of 129266000 | Measurement - action (qualifier value)| or one of its subtypes that is also specified in the concept definition. That is, use of 370129005 | Measurement method (attribute)| must be in addition to a 260686004 | Method (attribute)| of 129266000 | Measurement - action (qualifier value)| or one of its subtypes.

Also, the 370129005 | Measurement method (attribute)| and its value must be grouped with the 260686004 | Method (attribute)| and its value of the concept or subtype of 129266000 | Measurement - action (qualifier value)| .

For example,

• 442165003 | Quantitative measurement of polychlorinated biphenyl in blood specimen using gas chromatography (procedure)| has a 370129005 | Measurement method (attribute)| of 2842000 | Gas chromatography measurement (procedure)|

Property specifies the kind of property (quality or characteristic) being measured.

For example,

• 19165008 | Measurement of limb length (procedure)| has a 370130000 | Property (attribute)| of 410668003 | Length property (qualifier value)|

Scale Type refers to the scale of the result of an observation of a diagnostic test.

For example,

• 442165003 | Quantitative measurement of polychlorinated biphenyl in blood specimen using gas chromatography (procedure)| has 370132008 | Scale type (attribute)| of 30766002 | Quantitative (qualifier value)|

Time Aspect specifies temporal relationships for a measurement procedure. While this attribute has been approved, guidelines for its implementation await development.

An evaluation procedure may evaluate a property of a component, or a property may be the sole focus of the method. In the latter case, component isn’t included since only the property is being evaluated.

For example - an evaluation procedure evaluating a property of a component:

• 443834000 | Quantitative measurement of mass concentration of bismuth in urine specimen (procedure)| has 370130000 | Property (attribute)| of 118539007 | Mass concentration (property) (qualifier value)| and 246093002 | Component (attribute)| of 23172004 | Bismuth (substance)|

For example - where property may be the sole focus of the method:

• 78888000 | Osmolality measurement, urine (procedure)|

SNOMED CT has attribute hierarchies for Procedure Site, Procedure Device, and Procedure Morphology. Each has two sub-attributes to represent the direct and indirect object s. Procedure Device also has more specific attributes, Using Device and Using Access Device.

The potential for an endless number of combined procedures that may be performed in the same encounter requires more stringent criteria for addition. Combined procedures acceptable for precoordination are those that represent multiple individual procedures done in sequence or in combination, related to the same focal condition, and performed within the same encounter. These procedures must be sufficiently defined to be added.

The observable entity and evaluation procedure hierarchies have some of the same attributes. There is not and should not be a one-to-one correspondence between the two hierarchies.

Concepts will not be duplicated between the observable entity hierarchy and procedure hierarchy, and requests for such will not be added. While some users have indicated they want to use a procedure concept for ordering a test and an observable concept for reporting the result, this is not an acceptable use case. Please see for more information.

The evaluation procedure hierarchy is currently classified under Procedure by method , with many immediate children as follows:

Excision, incision, and biopsy may be difficult to interpret. They are organized according to the following general structure.

Organ excision. Any excisional act involving the organ; usually (organ)-ectomy, or similar, is a synonym. Organ excision , itself, does not specify whether it is complete or partial, nor does it specify what is excised.

For example,

• 23968004 |Excision of colon (procedure)| or one of the synonyms, Colectomy

Concepts may include complete or total to indicate complete removal or excision of the organ.

For example,

Simple fluoroscopy is real time imaging (usually on TV monitors/image intensifiers) of a body part or system. Only rarely is it an imaging process alone (without some interventional procedure). Fluoroscopy is most often used to guide or direct a primary procedure/purpose. The usual convention in clinical practice is to ignore the fluoroscopic element and refer to a procedure entirely by the primary component, e.g., angiography. However, this is unacceptable in SNOMED CT, where the imaging component must be explicitly described.

• FSN: Fluoroscopy of X (procedure)

• PT: Fluoroscopy of X

Monitoring of any type is not a notion to be included in SNOMED CT, as it is not really an orderable, and clearly not a resultable, concept. There are 450 subtypes of 239516002 |Monitoring procedure (regime/therapy)| that will eventually be inactivated; new concepts with this label are not to be added.

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Ultrasonography

• FSN: Ultrasonography of X (procedure)

• PT: Ultrasonography of X

• SYN: Ultrasound scan of X

• SYN: Ultrasound of X

  • For example,

    • 709590000 | Ultrasonography of perineum (procedure)|

      • FSN: Ultrasonography of perineum (procedure)

      • PT: Ultrasonography of perineum

• FSN: Doppler ultrasonography of X (procedure)

• PT: Doppler ultrasonography of X

• SYN: Doppler ultrasound scan of X

  • For example,

An obstetric ultrasound may require a complex description. However, the same rules apply, as follows:

• FSN: Obstetric ultrasonography of X (procedure)

• PT: Obstetric ultrasonography of X

• SYN: Obstetric ultrasound scan of X

• SYN: Obstetric ultrasound of X

Nuclear medicine imaging uses radionuclides or radioisotopes.

Radionuclide imaging

• FSN: Radionuclide imaging of X (procedure)

• PT: Radionuclide imaging of X

• SYN: Radioisotope imaging of X

  • For example,

    • 710313004 | Radionuclide imaging of peritoneal cavity (procedure)|

      • FSN: Radionuclide imaging of peritoneal cavity (procedure)

      • PT: Radionuclide imaging of peritoneal cavity

• FSN: Radionuclide imaging of X using Y (procedure)

• PT: Radionuclide imaging of X using Y

• SYN: Radioisotope imaging of X using Y

  • For example,

It is essential to express when contrast is part of a procedure and that descriptions are constructed consistently.

• For example,

  • 702501008 | Computed tomography of knee with contrast (procedure)|

    • FSN: Computed tomography of knee with contrast (procedure)

    • PT: CT of knee with contrast

    • SYN: Computed tomography of knee with contrast

The descriptions for all procedure concepts that use contrast must explicitly state ‘with contrast.’ All procedures that use contrast, including 420040002 |Fluoroscopic angiography with contrast (procedure)| and all subtypes, must include the attribute 424361007 |Using substance (attribute)| and a value of 385420005 |Contrast media (substance)| or a subtype in the role group.

Where the value for the method imaging action is 278110001 |Radiographic imaging - action (qualifier value)| or a subtype, the value for 424361007 |Using substance (attribute)| must be 419098001 |Radiographic imaging contrast media (substance)| or a subtype to denote the radio-opaque nature of the substance.

• Exception: procedures which specify negative contrast which is non-radio-opaque

It is unnecessary to add the word media to contrast.

It is agreed that the linking word to associate the contrast use with the procedure is with - not for, or, etc.

Although considered a negation, this term is used in clinical records. Without contrast imaging procedures are acceptable.

For example,

• 566341000119106 | Computed tomography of ankle without contrast (procedure)|

  • FSN: Computed tomography of ankle without contrast (procedure)

  • PT: CT of ankle without contrast

  • SYN: Computed tomography of ankle without contrast

With and without and With or without imaging concepts are not acceptable due to ambiguity. Two concepts should be used to express these separately.

Centesis may be defined as the act of puncturing a body cavity or space with a hollow needle and drawing out fluid. Each centesis procedure involves both a puncture action and a needle aspiration action. It is correct to have two relationship groups for centesis procedures.

One group has a Method (attribute) of Puncture - action (qualifier value) and a Procedure site - Direct (attribute) of the structure being punctured.

A second group has a Method (attribute) of Aspiration - action (qualifier value) and a Procedure site - Indirect (attribute) of the space being aspirated.

• For example,

  • 91602002 |Thoracentesis (procedure)| has:

    • Role group 1:

      • Method = Puncture - action

      • Procedure site - Direct (attribute) = Pleural membrane structure (body structure)

      • Using device = Needle, device

A distinction is needed between stoma procedures and procedures where an anastomosis is created between two hollow organs.

A stoma is a surgically created opening connecting an internal body structure to the external skin surface. Although most commonly formed on the abdominal wall, stomas can be created at other anatomical sites, such as the neck (tracheostomy) or perineum (perineal urethrostomy). The defining criterion is cutaneous externalization.

In contrast, internal anastomoses between two visceral structures, such as an entero-enterostomy or ureterointestinal anastomosis, while often referred to as internal stomas are not classified as stomas, as they lack cutaneous communication or exteriorization.

The morphologies resulting from these two different types of procedures may both be termed using the suffix ostomy, but they mean different things:

• For example,

Imaging guidance can be modeled using the Has intent (attribute). The concept 429892002 |Guidance intent (qualifier value)|, a child of 363675004 |Intents (nature of procedure values) (qualifier value)|, is the value for the Has intent (attribute) for imaging-guided procedures.

• For example,

  • 432666003 |Biopsy of brain using computed tomography guidance (procedure)| has two relationship groups:

    • Group 1:

      • Method (attribute) of Biopsy - action (qualifier value)

      • Procedure Site - Direct (attribute) of Brain structure (body structure)

    • Group 2:

      • Procedure Site - Direct (attribute) of Brain structure (body structure)

      • Method (attribute) of Computed tomography imaging - action (qualifier value)

      • Has intent (attribute) of Guidance intent (qualifier value)

Where the procedure involves a device and/or morphology as the object of the action for which imaging guidance is being performed, that morphology, device, and/or anatomic structure in/on which the procedure is being performed are all the direct object of the imaging action. The direct device or direct morphology is included in the imaging role group.

• For example,

  • In Aspiration of cyst using ultrasonic guidance (procedure), the Ultrasound imaging role group will include a Direct morphology (attribute) of Cyst (morphologic abnormality).

X using fluoroscopic guidance (procedure) is a subtype of Fluoroscopy (procedure).

• For example,

  • 710291004 |Endoscopy using fluoroscopic guidance (procedure)| has the following relationship groups

    • Group 1:

      • Using device (attribute) of Endoscopic device (physical object)

Where a procedure is undertaken during a specific period of life, such as in the maternal pregnancy period, the descriptions may include the term during. However, the concept is modeled with Occurrence (attribute) with a value of <282032007 |Periods of life (qualifier value)|.

• For example,

  • 1287360000 | Injection of epidural anesthesia during maternal intrapartum period (procedure)| has an Occurrence (attribute)| of 1156682000 |Maternal intrapartum period (qualifier value)|.

Obstetric procedures

Obstetric procedure (procedure) is modeled with two GCI axioms using the Occurrence (attribute) with a value of either Maternal perinatal period (qualifier value) or Pregnancy time period (qualifier value).

There are two modeling patterns for procedures containing obstetric in descriptions.

For procedures containing obstetric in descriptions, but a specific maternal period cannot be determined, concepts should be modeled using |Obstetric procedure| as the primitive parent concept and fully defined by a specific method.

For example, Obstetric operation (procedure) is fully defined by the parent |Obstetric procedure| and the Method (attribute) of Surgical action (qualifier value).

For procedures which a specific maternal period can be determined, the primitive parent is |Procedure| with Occurrence of either <<Maternal perinatal period (qualifier value) or <<Pregnancy time period (qualifier value).

For example, Diagnostic ultrasound of gravid uterus (procedure) can be fully defined by |Procedure| and Ultrasound imaging of the Uterus with Occurrence of Maternal antenatal and/or intrapartum time period (qualifier value).

Fetal procedures are fully defined by an Occurrence (attribute) of <<Fetal period (qualifier value). Generic body structures, for example, kidney, head, etc., should be used for procedure sites, unless the structure is unique to a fetus. Structures not unique to a fetus, such as, fetal head, fetal kidney, etc., will be inactivated in future releases, so they should not be used for modeling fetal procedures.

For example, Ultrasonography of fetal head (procedure) can be fully defined by |Procedure| and Ultrasound imaging of the Head with the Occurrence (attribute) of Fetal period (qualifier value).

Single photon emission computerized tomography (procedure)

• FSN: Single photon emission computed tomography of X (procedure)

• PT: Single photon emission computed tomography of X

• SYN: SPECT of X

  • For example,

    • 709549003 | Single photon emission computed tomography of heart (procedure)|

      • FSN: Single photon emission computed tomography of heart (procedure)

      • PT: Single photon emission computed tomography of heart

      • SYN: SPECT of heart

Chemotherapy regimens, which are internationally recognized and implemented, are acceptable content and may be added to the (regime/therapy) hierarchy as subtypes of 716872004 | Antineoplastic chemotherapy regimen (regime/therapy)|.

Trade names, which are indicated by an acronym, e.g. ABVD chemotherapy regimen, where A represents trade name Adriamycin®, should not be spelled out but may be referenced in the acronym used to describe the regimen.

Generic drug names are not capitalized; they are lower case. When creating descriptions for generic drug names, the substance described should match the description from the Substance hierarchy.

Examples,

ABVD chemotherapy regimen. A represents the trade name Adriamycin® (INN = doxorubicin):

• FSN: Doxorubicin, bleomycin, vinblastine and dacarbazine chemotherapy regimen (regime/therapy)

  • PT: ABVD chemotherapy regimen

  • Synonym: Doxorubicin, bleomycin, vinblastine and dacarbazine chemotherapy regimen

  • Synonym: ABVD chemotherapy protocol

R-CHOP chemotherapy regimen.H represents the non-INN generic name hydroxydaunomycin (INN = doxorubicin) and O represents the trade name Oncovin® (INN = vincristine):

• FSN: Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy regimen (regime/therapy)

  • PT: R-CHOP chemotherapy regimen

  • Synonym: Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy regimen

  • Synonym: R-CHOP chemotherapy protocol

There are numerous procedures where the imaging component is considered a supplemental or secondary technique to help accomplish the primary goal. The pattern is:

Procedure using guidance

• FSN: Y using guidance (procedure)

• PT: guided Y

• SYN: Y using guidance

Computed tomography guided procedure

• FSN: Y using computed tomography guidance (procedure)

• PT: CT guided Y

• SYN: Y using computed tomography guidance

  • For example,

    • 431864000 | Injection using computed tomography guidance (procedure)|

      • FSN: Injection using computed tomography guidance (procedure)

• FSN: Y using fluoroscopic guidance (procedure)

• PT: Fluoroscopy guided Y

• SYN: Y using fluoroscopic guidance

  • For example,

(See also )

• FSN: Y using magnetic resonance imaging guidance (procedure)

• PT: MRI guided Y

• SYN: Y using magnetic resonance imaging guidance

  • For example,

• FSN: Y using ultrasonographic guidance (procedure)

• PT: Ultrasonography guided Y

• SYN: Y using ultrasonographic guidance

• SYN: Y using ultrasound guidance

• FSN: Y using plain X-ray guidance (procedure)

• PT: Plain X-ray guided Y

• SYN: Y using plain X-ray guidance

  • For example,

A regime/therapy is a set, sequence, or group of procedures. 243120004 |Regimes and therapies (regime/therapy)| is a subtype of Procedure (procedure). As a subtype of procedure, Regimes and therapies have the same attributes and use the same concept model as general procedures.

Regime and therapies are either repeated multiple times or performed over an extended period of time.

• For example,

  • 716872004 |Antineoplastic chemotherapy regimen (regime/therapy)|

    • This regime/therapy might include individual instances of administration of chemotherapy agents; the instances are at separate, predetermined periods of time.

• 229586001 |Rest, ice, compression and elevation treatment program (regime/therapy)|

  • This regime/therapy refers to repeated rest, ice, compression and elevation (RICE) for an indefinite period of time.

Regime and therapies are focused on a single purpose but do not have any single sub-procedure as a necessary part.

For example,

• 385695003 |Cast care (regime/therapy)|, The sub-procedures are all done for the purpose of properly monitoring and maintaining an orthopedic cast, but the sub-procedures may vary from one cast, patient, or healthcare setting to the next. Sub-procedures may include inspecting the cast, checking the skin, reinforcing padding, etc. There is not a single sub-procedure as a necessary part, although the purpose of the sub-procedures is to take care of a cast.

  • It is possible to have a regime/therapy as an instance of care. An instance of cast care could be the specific care for Mr. Smith's cast on the morning of April 23rd, consisting of the set of procedures: examining the cast; examining his arm; asking about his symptoms; and cleaning the skin.

Computed tomography

• FSN: Computed tomography of X (procedure)

• PT: CT of X

• SYN: Computed tomography of X

• For example,

  • 241566009 | Computed tomography of elbow (procedure)|

    • FSN: Computed tomography of elbow (procedure)

    • PT: CT of elbow

    • SYN: Computed tomography of elbow

This naming pattern is used when an anatomical location is specified, but the blood vessel is not explicit.

• FSN: Computed tomography angiography of X with contrast (procedure)

• PT: CT angiography of X with contrast

• SYN: Computed tomography angiography of X with contrast

  • For example,

• FSN: Computed tomography angiography of [artery] with contrast (procedure)

• PT: CT angiography of [artery] with contrast

• SYN: CT arteriography of [body structure] with contrast

• SYN: Computed tomography arteriography of [body structure] with contrast

• FSN: Computed tomography venography of X with contrast (procedure)

• PT: CT venography of X with contrast

• SYN: CT venogram of X with contrast

• SYN: Computed tomography venography of X with contrast

• FSN: Computed tomography arthrography of X (procedure)

• PT: CT arthrography of X

• SYN: CT arthrogram of X

• SYN: Computed tomography arthrography of X

As mentioned in the initial Surgical procedures page, the definition of surgical procedure includes intentional non-transient alteration of structures of the body and/or necessarily involves cutting into the body.

Non-surgical actions do not significantly or non-transiently alter anatomy and do not necessarily involve cutting or incision.

• For example,

  • Fine needle biopsy (procedure) or brush biopsy (procedure)

  • Phlebotomy, a synonym for venipuncture for blood test (procedure)

  • Aspiration (procedure)

  • Closed reduction of dislocation (procedure)

Closed procedure naming

• The general pattern <open, closed> is accepted

• When a procedure is specified as closed, the closed procedure should be fully described, e.g. fine needle biopsy, endoscopic, etc.

Immunization may be active (introduction of a vaccine) or passive (introduction of immunoglobulin/antibodies). A vaccine is a substance that can induce active immunity. Vaccination, by definition, is the introduction of a vaccine, and is, therefore, synonymous with active immunization. Some descriptions include the word vaccination, where it is clear that vaccination is intended. Other descriptions have preferred terms with the word vaccination, and synonyms with the word immunization, to include both active and passive immunization.

• For example,

  • 38598009 |Measles-mumps-rubella vaccination (procedure)| has vaccination in all descriptions

  • 86198006 |Influenza vaccination (procedure)| has the synonym, influenza immunization

A surgical procedure is defined as a procedure that involves intentional non-transient alteration of structures of the body, and/or a procedure that necessarily involves cutting into the body. This definition includes all procedures defined by Method (attribute) with Surgical action (qualifier value).

SNOMED CT classifies concepts as surgical procedures if their methods are surgical actions based on the action hierarchy. The surgical action hierarchy distinguishes surgical from non-surgical actions based on the definition above. Note the Or in the sentence; actions that do not involve cutting or incision, but do involve the intentional non-transient alteration of anatomy, are still surgical.

Surgical procedures are not defined simply as procedures done by a surgeon (despite some dictionary definitions). Surgeons can perform many non-surgical actions and surgical procedures need not necessarily be performed by a surgeon, i.e. if a non-surgeon performs a surgical procedure, it is still a surgical procedure.

Multi-step Procedures

While many dental procedures are performed by completing a series of individual steps, the descriptions and modeling of the complete or comprehensive procedure should simply outline the core steps. These are steps that are necessarily true in order to describe the concept. Steps that are part of a protocol, but not necessary, should not be included. Multi-step procedures may be performed in one clinical session or split over several sessions. Where possible, a definition should be added to new concepts of this type.

• For example,

  • In the following concept 1381619006 |Preparation and obturation of root canal of tooth using root canal filling material (procedure)|, preparation and obturation describe the core steps. Irrigation, which often is part of the protocol, is not included.

Individual procedural steps can be modeled as separate concepts when required by a use case, for example, 234707000 |Root canal preparation (procedure)|.

For restorative procedures, descriptions should follow the format: Restoration of tooth by insertion of [substance or device].

• For example,

  • 1381884009 |Direct restoration of tooth by insertion of composite dental material (procedure)|

Procedures on a tooth should be modeled with 38199008 |Tooth structure (body structure)| and state tooth in descriptions.

• For example,

  • 1259948005 |Repair of fissure sealant on tooth (procedure)|

Where a procedure acts on multiple teeth, these concepts should be modeled with 245543004 |Structure of dentition (body structure)| and state teeth in descriptions.

• For example,

  • 1260193009 |Removal of accretion from teeth using dental scaler (procedure)|

General rules

The naming pattern for procedures is highly dependent on the attributes used to describe the procedure. However, some general rules apply.

The FSN for a procedure should name the action (the method) of the procedure first, and then the object that the action directly acts upon.

• For example,

  • 261531000 | Excision of rib (procedure)|

Include the approach where more than one option exists. See the various approaches as subtypes of 103379005 |Procedural approach (qualifier value)|.

• For example,

  • 386792000 Transurethral resection of neoplasm of bladder (procedure) vs 287726000 Open resection of neoplasm of bladder (procedure)

Because a resection of a neoplasm of the bladder can be performed by transurethral and open approaches, concepts are separately identified with each approach.

One description, either preferred term or synonym, should match the FSN without the semantic tag. Synonyms and/or preferred terms using the common clinical names of procedures are acceptable.

A common naming pattern for concepts in the procedure hierarchy is:

FSN: <Method (Action)> of (procedure)

PT: <Method (Action)> of

SYN: [plasty/stomy/ectomy/otomy]

• For example,

  • 82035006 | Resection of polyp (procedure)| has a synonym of polypectomy

Further refinements can be affected by the various attributes and their values as described in the sections below.

An anatomical site is the direct object of the action. The name of the site should follow the name of the action.

For example,

• 175253007 | Repair of pulmonary artery (procedure)|

The action is repair and the site is pulmonary artery. The action is listed first in the description, followed by the site.

Procedure descriptions should follow the naming guidelines for the body structure hierarchy. Concepts describing limbs are frequently found in SNOMED CT, and the use of upper/lower limb in the FSN with synonyms of upper/lower extremity, arm/leg should be followed.

For example,

• 179987000 | Replantation of upper limb (procedure)|

  • The description of upper limb is used in the FSN while the synonyms refer to arm and upper extremity.

A device is the direct object of the action. The word(s) naming the device should follow the word(s) naming the action. If there is a site that is not the direct object of the action, the word(s) naming it should come after the word(s) naming the device.

For example,

• 392247006 | Insertion of catheter into artery (procedure)|. The action is insertion , the direct object is catheter , and the indirect site is artery.

A substance is the direct object of the action. The word(s) that name the substance should follow the words that name the action. If there is a site that is not the direct object of the action, the word(s) naming it should follow the word(s) naming the substance.

For example,

• 427258004 | Injection of hormone into subcutaneous tissue (procedure)|. The action is injection , the direct object is hormone , and the indirect site is subcutaneous tissue.

A morphologic abnormality is the direct object of the action. The morphology term should follow the action term. If there is a site, it should follow the morphology term.

For example,

• 41180005 | Excision of cyst of breast (procedure)|. The action is excision, the direct object is the morphologic abnormality cyst , and the site is breast.

• 175376008 | Operation on aneurysm of carotid artery (procedure)|. The action is operation , the direct object is the morphologic abnormality aneurysm, and the site is carotid artery.

A procedure concept should be a noun phrase that names the procedure. It should not contain information that it was done, or is to be ordered, carried out, or planned.

• Past tense verbal phrases should not be used to name procedures, since past tense invokes a temporal context, i.e. the procedure was done in the past. Any existing concepts with past tense verbs should be moved to the Situation with explicit context hierarchy.

• Sentence function types, i.e. imperative, declarative, interrogative, or exclamatory, are disallowed in procedure concepts.

Acceptable example,

• 11227005 | Excision of ganglion of tendon sheath of hand (procedure)|. This is an acceptable FSN expressed with a noun phrase.

Unacceptable example,

• Hand tendon ganglion excised indicates the procedure was done, as a past tense declarative statement. This should be in the Situation with explicit context hierarchy, not the Procedure hierarchy.

Complexity can mean either the amount of effort required, or it can be based on realm-specific definitions (e.g., simple arthrodesis, simple repair, complex repair, etc.). Procedure concepts with modifiers representing complexity are not allowed in the International Release.

Positron emission tomography (procedure)

• FSN: Positron emission tomography of X (procedure)

• PT: PET of X

• SYN: Positron emission tomography of X

  • For example,

    • 702767007 | Positron emission tomography of whole body (procedure)|

      • FSN: Positron emission tomography of whole body (procedure)

      • PT: PET of whole body

      • SYN: Positron emission tomography of whole body

In a transplant procedure, the transplanted organ or tissue may not be in the same place as the original organ/structure, and the original organ/structure may or may not remain in situ.

• For example, 70536003 |Transplant of kidney (procedure)|

  • In most kidney transplants, the recipient’s own kidneys remain in situ, but in some cases the kidney is removed. The new kidney is usually placed in the right iliac fossa, but not always; it can be placed in the left iliac fossa, retroperitoneal area, or sometimes within the abdominal cavity.

Due to these reasons, encompassing a variety of scenarios depending on each particular organ and patient, << 24486003 |Structure of transplant (body structure)| is used for the target for 405813007 |Procedure site - Direct (attribute)| for transplantation procedures.

• For example, 32413006 |Transplantation of heart (procedure)|

363701004 |Direct substance (attribute)| relationship is only utilized where it adds additional information (autograft, allograft, etc).

• For example, 232973007 |Allotransplant of heart (procedure)|

Consultation established that for tissue transplants, graft and transplant are used interchangeably with the preferred option being grafting procedure, with a transplant description placed as a synonym on the grafting procedure concept.

• For example, 27493007 |Peripheral nerve graft (procedure)|

See for grafting procedure guidance.

Magnetic resonance imaging

Descriptions:

• FSN: Magnetic resonance imaging of X (procedure)

• PT: MRI of X

• SYN: Magnetic resonance imaging of X

  • For example,

    • 6007000 | Magnetic resonance imaging of chest (procedure)|

      • FSN: Magnetic resonance imaging of chest (procedure)

      • PT: MRI of chest

Descriptions:

• FSN: Magnetic resonance angiography of X (procedure)

• PT: Magnetic resonance angiography of X

• SYN: Magnetic resonance angiogram of X

• SYN: MR angiography of X

Descriptions:

• FSN: Magnetic resonance venography of X (procedure)

• PT: Magnetic resonance venography of X

• SYN: Magnetic resonance venogram of X

• SYN: MR venography of X

Descriptions:

• FSN: Magnetic resonance arthrography of X (procedure)

• PT: Magnetic resonance arthrography of X

• SYN: Magnetic resonance arthrogram of X

• SYN: MR arthrography of X

Descriptions:

• FSN: Magnetic resonance spectroscopy of X (procedure)

• PT: Magnetic resonance spectroscopy of X

• SYN: MR spectroscopy of X

  • For example,

The following defining attributes correspond to the Procedure Attributes Summary table.

Access

Access (attribute) describes the route used to access the site of a procedure. It distinguishes open, closed, and percutaneous procedures.

• For example,

  • 174572001 | Open removal of bile duct stent (procedure)| has |Access (attribute)| of Open approach - access (qualifier value)

The Access (attribute) should only be used if there is more than one possible route for that specific procedure.

• For example,

  • Cesarean section (procedure) does not need the Access (attribute) because open is the only possible route.

If a procedure (like a biopsy) can be done via multiple routes, the Access (attribute) must be used if the route is inherent to that specific procedure, even if the FSN does not explicitly state it. For all new procedures, if multiple routes are possible, the specific access route must be stated in the FSN. Legacy content will be addressed as resources allow.

Direct device (attribute) represents the device on which the method directly acts.

For example,

• 431698006 | Adjustment of gastric banding using fluoroscopic guidance (procedure)| has Direct device of Surgical band (physical object)

Direct morphology (attribute) describes the morphologically abnormal structure that is the direct object of the Method action.

For example,

• 31512000 | Shaving of benign lesion with chemical cauterization (procedure)| has the Direct morphology of Lesion (morphologic abnormality)

Direct substance (attribute) describes the Substance or Pharmaceutical/biologic product on which the procedure's method directly acts.

For example,

• 231274008 |Injection of steroid into joint (procedure)| has Direct substance (attribute) of Steroid (substance)

Has focus (attribute) specifies the Clinical finding or Procedure which is the focus of a procedure. This attribute is self-grouped.

For example,

• 385941006 | Wound care assessment (procedure)| Has focus of Wound care (regime/therapy)

The Has intent attribute is used when a procedure may be performed for various reasons, described with subtypes of 363675004 |Intents (nature of procedure values) (qualifier value)|, such as diagnostic, palliative, preventive, therapeutic, etc. These intents are not used to define procedures with intents that are inherent to the procedure; such as biopsies that are by definition diagnostic, or fracture fixations which are always therapeutic.

The Has intent attribute should be grouped with other attributes that represent the procedure with that intent.

For example,

• 108249004 | Audiologic AND/OR audiometric test including vestibular function (procedure)| is inherently diagnostic, so it would not be modeled with a Has intent (attribute) of Diagnostic intent (qualifier value).

• 274432006 | Therapeutic aspiration of ovary (procedure)| and 274389009 | Diagnostic aspiration of ovary (procedure)| are both modeled with the Has intent (attribute), as the aspiration of ovary procedure can be either therapeutic or diagnostic.

Indirect device (attribute) represents action on something that is located in or on a device, but is not directly on the device itself. This attribute is infrequently needed. When modeling, carefully consider its use.

For example,

• 232762008 | Excision of vegetations from implanted mitral valve (procedure)| has Indirect device of Mitral valve prosthesis device (physical object).

  • In this example, the vegetation is being excised. The mitral valve prosthesis device is where the vegetation is located, but the mitral valve prosthesis, itself, is not excised. Thus, the mitral valve prosthesis device is the Indirect device.

Indirect morphology (attribute) describes the morphology that is acted upon, but is not the direct object of the Method action. This means the procedure acts directly on something else, e.g., a device, substance, or anatomical structure.

For example,

• 404205006 | Removal of mesh from wound (procedure)| has Indirect morphology of Wound (morphologic abnormality)

Method (attribute) represents the action being performed to accomplish the procedure.

For example,

• 10255001 | Incision of ureter (procedure)| has Method (attribute) of Incision - action (qualifier value)

Procedures with a Method (attribute) can be described using an action verb that corresponds to the method. The direct object/s of the action verb should be represented using one or more of the four direct-object attributes, depending on whether the direct object on which the method acts is an:

• Anatomical structure: Procedure site - Direct

• Morphologic abnormality: Direct morphology

• Device: Direct Device

• Substance: Direct Substance

If the anatomical structure, device, or substance of the direct object is indeterminate, do not use the direct-object attributes.

When modeling procedures where the Method is Removal - action (qualifier value) or one of its subtypes, e.g. Excision, Surgical biopsy, etc., for removal of:

• Structures, grafts, and tissue lesions (e.g., cysts, tumors, etc. are considered removal of the site), use Procedure site - Direct.

• Devices, calculi, thrombi, foreign bodies, and other non-tissue entities from the structure, use Procedure site - Indirect.

For example,

• 43748006 |Removal of urinary bladder catheter (procedure)| has a Method (attribute) of Removal - action (qualifier value). Because a device is being removed, use Procedure site - Indirect (attribute) with a value of Bladder and outflow structure (body structure)

Method (attribute) does not describe

• procedure approach, e.g., translumbar

• equipment, e.g., sutures

• physical force, e.g., laser energy

Attributes should be grouped with the Method (attribute) to which they apply. In the absence of a Method (attribute), related attributes should be grouped together.

Exception,

• Recipient category (attribute)

  • A single procedure concept should not be precoordinated when more than one Recipient Category is involved. Such complex statements should have two or more procedure concepts that are placed into an appropriately structured electronic health application.

  • See separate attribute entry for below.

No relationship group can contain more than one Method (attribute). If a procedure has more than one method, each Method (attribute) serves as the anchor of a separate relationship group that will contain any defining relationships that represent a direct object (and, where relevant, indirect object) of the Method's action. This is true even if the different Methods each act on the same direct object. Each relationship group can be thought of as representing a component of the procedure that involves a particular action.

Occurrence (attribute) is applied to procedures during a period of life. For example, procedures related to the gravid uterus should be modeled by the combination of the occurrence of the maternal pregnancy period and the uterus.

Priority (attribute) is used when a procedure concept specifies a priority. This attribute is self-grouped.

For example,

• 708932005 | Emergency hemodialysis (procedure)| has Priority of Emergency (qualifier value)

• 177141003 | Elective cesarean section (procedure)| has Priority of Elective (qualifier value)

260870009 | Priority (attribute)| is most often used to differentiate elective and emergency subtypes of a procedure that can be performed on either basis. With the exception of Cardiopulmonary resuscitation (procedure), this attribute is normally used only to define concepts whose FSNs specify a priority, not for modeling procedures that imply an emergency priority, such as |Heimlich maneuver (procedure)| or those that are inherently elective, such as |Augmentation mammoplasty (procedure)|.

Procedure approach (attribute) specifies the directional, relational, or spatial access to the site of a procedure. The range for 116688005 |Procedure approach (attribute)| is << 103379005 |Procedural approach (qualifier value)| .

For example,

• 841021000000107 |Trabeculotomy by internal approach (procedure)| using |Internal approach (qualifier value)|

• 6421000087103 |Fluoroscopic antegrade pyelography of right renal pelvis (procedure)| using |Antegrade approach (qualifier value)|

Procedure device (attribute) is used to model devices associated with a procedure. This attribute is used to define high-level, general concepts that aggregate procedures according to the device involved.

Procedure device subsumes the more specific attributes, Direct Device, Indirect Device, Using Device, and Using Access Device. The more specific attributes should be used instead of Procedure Device, if possible.

For example,

• 276272002 | Catheter procedure (procedure)| has Procedure device (attribute) of Catheter, device (physical object)

Procedure morphology (attribute) is used to specify the morphology, or abnormal structure, involved in a procedure. It is used when defining general concepts that subsume direct and indirect morphology. It subsumes the more specific attributes, Direct and Indirect Morphology. These should be used, if possible.

Procedure site (attribute) describes the body site acted on or affected by a procedure. The Procedure site (attribute) is

• used to model the site for high-level grouping-type procedure concepts

• most often used for concepts that do not require a 260686004 | Method (attribute)| and 129264002 | Action (qualifier value)| pair

• not required in order for the classifier to work properly

363704007 | Procedure site (attribute)| subsumes the more specific attributes, 405813007 | Procedure site - Direct (attribute)| , which is the site directly acted upon, and 405814001 | Procedure site - Indirect (attribute)| , which is the site indirectly acted upon. The more specific attributes should be used if possible (see separate entries for Procedure site - Direct and Procedure site - Indirect).

For example,

• 118839001 | Procedure on colon (procedure)| has Procedure site of Colon structure (body structure)

When modeling procedures where the Method is Removal - action (qualifier value) or one of its subtypes, e.g., Excision, Surgical biopsy, etc., for removal of:

• Structures, grafts, and tissue lesions (e.g., cysts, neoplasms, abscesses, wounds, warts, aneurysms, herniations, oral clefts, etc.) are considered removal of the site, use Procedure site - Direct.

• Devices, calculi, thrombi, foreign bodies, and other non-tissue entities from the structure, use Procedure site - Indirect.

Structure of <anatomical structure> rather than Entire <anatomical structure> should be used as the value for procedure site attributes, except where the procedure FSN explicitly specified that the entire structure is the object of the procedure.

For example,

• 23968004 | Excision of colon (procedure)| has 405813007 | Procedure site - Direct (attribute)| of 71854001 | Colon structure (body structure)|

• 26390003 | Total colectomy (procedure)| has 405813007 | Procedure site - Direct (attribute)| of 302508007 | Entire colon (body structure)|

Procedure site - Direct (attribute) is used when the action of the procedure is directly aimed at anatomical or acquired body structure or site, rather than something else located there (e.g., a device), i.e., when the 260686004 | Method (attribute)| is 129303008 | Removal - action (qualifier value)| or one of its subtypes (Excision, Surgical biopsy, etc.).

For example,

• 54321008 | Cardiac flow imaging (procedure)| has 405813007 | Procedure site - Direct (attribute)| of Coronary artery structure (body structure)

Tissue lesions (cysts, neoplasms, abscesses, wounds, warts, aneurysms, herniations, oral clefts, etc.) are considered part of the procedure site and should also use 405813007 | Procedure site - Direct (attribute)| .

For example,

• Repair of rectocele (procedure) has a Procedure site - Direct (attribute) of Rectum structure and a Direct morphology (attribute) of Herniated structure

• Closure of skin wound (procedure) has a Procedure site - Direct (attribute) of Skin structure and a Direct morphology (attribute) of Wound

• Fixation of fracture (procedure) has a Procedure site - Direct (attribute) of Bone structure and a Direct morphology (attribute) of Fracture

Procedure site - Indirect (attribute) specifies the anatomical location but is not the direct focus of the procedure. The direct object of the action may be a device, a substance, or a morphologic abnormality that is not a part of the tissue structure of the anatomical site in which it is located, such as a calculus, thrombus, or foreign body. Thus, 405814001 | Procedure site - Indirect (attribute)| is typically found in a relationship group with a second, "direct" attribute-value relationship, such as a Direct morphology, Direct substance, or Direct device.

For example,

• 405433000 | Removal of catheter from brachial vein (procedure)| has:

  • Method of Removal - action (qualifier value)

  • Procedure site - Indirect of Structure of brachial vein (body structure)

  • Direct device of Venous catheter (physical object)

Recipient category (attribute) specifies the type of individual or group upon which the action of the procedure is performed.

For example,

• 105455006 | Donor for medical or surgical procedure (person)| has Recipient Category (attribute) of Donor if the subject of the record is the Blood product donor (person).

This can be used in blood banking procedures to differentiate the donor vs the recipient of blood products.

Revision status (attribute) refers to another procedure performed on the same site for the same condition. A procedure without a revision status is considered to be performed for the first time. A revision procedure can be modeled with a Revision status (attribute) of Revision - value (qualifier value).

For example,

• 128323000 | Revision of implant (procedure)| has a Revision status (attribute) of Revision - value (qualifier value)

Route of administration represents the route by which a procedure introduces a substance into the body. The range involves subtypes of 284009009 |Route of administration value (qualifier value)|. When using this attribute, an additional attribute of |Procedure site - indirect| should be modeled and grouped with the |Route of administration (attribute)|.

For example,

• 410572008 | Injection of steroid via intravitreal route (procedure)| has the | Route of administration (attribute)| of Intravitreal route (qualifier value)

While the values for |Procedure site - Indirect| and |Route of administration| attributes may be similar and seem redundant, their presence is necessary for consistent subsumption.

Examples of complementary values of Route of administration and Procedure site - Indirect

Using access device (attribute) specifies the instrument or equipment used to access the site of a procedure.

For example,

• 274323008 | Endoscopic biopsy of colon (procedure)| has a Using access device (attribute) of Colonoscope, device (physical object)

Many procedures can be carried out using tools attached to or operated via channels within the endoscope. In some cases the device IS used for access (such as endoscopy of the GI tract), e.g. ERCP in particular allows you to both visualize and operate upon the sphincter of Oddi/ampulla of Vater using cutting devices (knives or wires etc.) and then passing a basket up into the CBD to remove stones. The correct attribute for the device is |Using access device (attribute)|.

Using device (attribute) refers to the instrument or equipment utilized to execute an action. It is used when the device is actually used to carry out the action, that is the focus of the procedure. If the device is simply the means to access the site of the procedure, then Using access device is the appropriate attribute.

For example,

• 51064005 | Core needle biopsy of larynx (procedure)| has a Using device (attribute) of Core biopsy needle, device (physical object)

When an Incision role group is included in the concept model, then |Using device| attribute is appended to the Inspection role group. For example, access to either the abdominal cavity or a joint capsule is achieved by an ordinary incision using a scalpel blade. The laparoscope or arthroscope is then introduced into the cavity through the incision, i.e. the endoscope is not the access device.

Using energy (attribute) refers to the energy used to execute an action.

For example,

• 65952009 | Gamma ray therapy (procedure)| has Using energy of Gamma radiation (physical force)

Using substance (attribute) describes the Substance used to execute the action of a procedure. It is not the substance on which the procedure's method directly acts, the Direct substance.

For example,

• 285754008 | Contrast radiography of esophagus (procedure)| has Using substance of Contrast media (substance)