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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:

  • User selection from a small list of possible Descriptions applicable to a particular field in a template or step in a protocol:
  • Text search limited to a set of Concepts applicable to a particular field in a template or step in a protocol:
  • Association of a Concept with particular options presented by a check box, option button or other data entry control:
    • When selections are made using this control the appropriate Concept Identifier is added to the record.
  • Association of a Concept with a data control used for entering a numeric or other value:
    • When a value is entered in this control it is labeled with the appropriated Concept Identifier .
  • Association of a Concept with a particular combination of values or the result of a computation involving several items of previously entered data:
    • In its simplest form this is an extension of one or both of the previous options;
    • In some applications, information derived from the user-entered data, by decision support tools, may be encoded in this way.

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.