Current Version - Under Revision
In many healthcare disciplines similar data sets are collected for each patient. Clinical consultations for many conditions involve repeatable sequences of data entry. These structured and predictable data entry requirements can be met using sets of customized data entry fields or forms (templates) designed to collect particular data items. These data entry templates may be presented in a predefined sequence, as selected by the user. Alternatively the sequence of data entry may follow a branching pathway with previously entered data determining which branches are taken (protocols).
When using a structured data entry mechanism, SNOMED CT encoded data can be selected in a variety of ways. Some of these involve direct selection of Concepts and Descriptions while in others the encoding may result from responses to simple choices or entry of particular data values. The following list outlines some of the possible mechanisms for SNOMED CT encoding during structured data entry:
Some installations allow free text to be entered at point of care if a needed concept is not included in the predefined short list. This text is then reviewed by trained staff who can then search and find the appropriate Concept, request the addition of a new Concept, and/or request that the Concept be added to the template's short list for future use. The success of this option relies upon trained staff who are available to do the review on a timely schedule, and the willingness of the clinician to use this approach sparingly, as it is greatly preferred to choose the appropriate concept and not enter free text.