Forward slash in FSN

A review has commenced of those concepts with a forward slash in their FSN.  Editorial guidance exists disallowing the use of forward slashes in FSNs, and we have commenced a systematic review of those existing terms containing them.

Many areas are excluded for example, medicinal products where strength /1 is the denominator, assessment scales, explicit "and/or", gene names, enzyme and other substance naming, organisms, ratios, per in units (or future consideration), intervertebral structures, content added with an Orphanet map and others. The review is ongoing.

If the meaning is clear i.e. single meaning there is no change but groupers, disjoint ('or)' terming and ambiguous terms will be reviewed and possibly inactivated or have a new replacement FSN without a forward slash. Subject matter experts are being consulted as part of this work.

Review of 129376004 |Construction - action (qualifier value)|

129376004 |Construction - action (qualifier value)| is a subtype of 257903006 |Repair - action (qualifier value) and sibling of 129377008 |Reconstruction - action (qualifier value)|.

Because some concepts modeled with 129376004 |Construction - action (qualifier value)| as target value concept for 260686004 |Method (attribute)| may not be considered a reparative procedure, a review of the 129376004 |Construction - action (qualifier value) and 410614008 |Construction (procedure)| hierarchies is being undertaken.

Expected outcomes may be the classification of 129376004 |Construction - action (qualifier value)| directly under 129284003 |Surgical action (qualifier value)| and the creation of new actions that better define the differences between reparative and construction procedures.

Genomic Community Content

Phenotype concepts that currently exist in the genomics community content area are being gradually promoted to the International edition release.  All content is being reviewed and revised based on the current international editorial guidelines and publication will occur incrementally over several releases.

Update - Abnormality of X

Many of the concepts for promotion from the community content represent the notion of "Abnormality of X", which will act as high level grouper concepts for existing SNOMED CT concepts. 

As "abnormality" can represent either a structural or functional defect in a body structure, these concepts will be termed specifically as "Structural abnormalities" or "Functional abnormalities" where appropriate.  Based on input from the SNOMED Editorial Advisory Group, existing "Abnormality of X" concepts in the International release will be reviewed for reterming to ensure that they specifically represent structural abnormalities. 

This will not result in any changes to the current hierarchies but will provide unambiguous descriptions for clarity and ease of translation.  

Additional Relationships

The new "additional relationships" take the same form as the inferred relationships and can be stored in the same format in the RF2 package. Modeling Advisory Group (MAG) recommends that extensions can use the existing relationship files or create new relationship files for them. By default, there is a single file for each component (1 concept file, 1 relationships file, 1 simple refset file, etc.). Edition and extension publishers can decide to split the content of any of those files for business reasons while following the naming convention. The new attributes should be placed under 1295449009 |Additional relationship attribute (attribute)|. The concept 900000000000227009 |Additional relationship (core metadata concept)| should be assigned to characteristicTypeId in the relationship files.

Inactivation and Replacement of Concepts Using "Arm" and "Leg" in the FSN 

Concepts that use "arm" or "leg" without qualification are ambiguous, as the anatomical site may be misinterpreted. Information on this topic can be found in the Arm, leg, upper, lower, extremity, limb section in the editorial guide here.

Work has commenced on updating Disorder content. Following this, Finding and Procedure content will be managed as resourcing permits. 

Notice of Deprecation - Concept Non Current Indicators

For further information please see here.

Inactivation of 363743006 |Navigational concept (navigational concept)

The entire navigational hierarchy : << 363743006 |Navigational concept (navigational concept)| will be inactivated in bulk with reason 'Non-conformance to Editorial Policy' and with no historical associations specified.

Navigational concepts were created to group other concepts without explicit regard for defining attributes (since there were none). Their purpose was to provide top level groupers for subsets and reference sets used in implementations.  Because the Reference Set mechanism is now available, there is no longer a need for navigational concepts in the International Release; however, they can be added at the national or lower level. 

New Disposition Groupers

As part of the quality improvement (QI) project following a gap analysis, additional disposition groupers will be incorporated into the medicinal product hierarchy. Medicinal Product (MP) groupers are subtypes of 766779001 |Medicinal product categorized by disposition (product)|. These new product groupers will align with the structure of the 766739005 |Substance categorized by disposition (substance)| hierarchy, specifically utilizing the "with x mechanism of action" substance disposition groupers, beginning with those representing a single disposition.
This work supports consistency across related hierarchies. For more information, please see here.

Update: a briefing note is in development and will be distributed for review and feedback.

Remodel 128928004 |Neuroendocrine neoplasm (morphologic abnormality)| and Subtypes

128928004 |Neuroendocrine neoplasm (morphologic abnormality)| its subtypes and related concepts in other hierarchies will be revised to align with the 5th edition of the WHO Blue Book chapter on Endocrine and Neuroendocrine Tumours as well as to SNOMED CT editorial guidance as part of the Histology Content Quality Group  Please see “Neuroendocrine neoplasms (NEN) - PART 2” here for more information about these changes.

Please see the Histology Content Quality Group site here for more information about the groups’ mission.

Planned Deprecation of the SNOMED CT - ICD-O version 3.1 Morphological and Topography Maps

Please see briefing note here.

Proposal to Increase the Character Limit for Descriptions

Inactivation of 715515008 |LOINC - SNOMED CT Cooperation Project module (core metadata concept)|

715515008 |LOINC - SNOMED CT Cooperation Project module (core metadata concept)| will be inactivated with reason outdated. It was previously used when the “LOINC Term to SNOMED CT Expression Reference Set” was released in 2017 under this module. As this reference set is no longer maintained or released, 715515008 | LOINC - SNOMED CT Cooperation Project module (core metadata) is not needed.

Please see http://loincsnomed.org for current information about the LOINC Ontology which has been released as an Extension of SNOMED CT.

Update to Aqueous Humor Drainage Device Structure and Related Procedures

Following collaboration with the Eye Care Clinical Reference Group (CRG), an update will be made to the SNOMED CT structure for aqueous humor drainage devices. This update reflects advancements in technology and aims to enhance the clarity of device descriptions.

Details of the proposed device hierarchy structure can be found here.

This change will also impact related procedure concepts, specifically 265291005 |Insertion of drainage tube into anterior chamber (procedure)| and subtypes. The current concepts will be inactivated and replaced due to the following reasons:

• The procedures described are implantations, not insertions.

• Earlier devices typically included plates; however, newer technologies include devices without plates.

• Drainage devices can be implanted in additional anatomical locations, such as the posterior chamber and the vitreous cavity/pars plana.

Example changes include:

• Inactivation of 265291005 |Insertion of drainage tube into anterior chamber (procedure)|, as outdated and replaced by:

• Implantation of subconjunctival aqueous humor drainage tube with plate into anterior chamber (procedure)

• Implantation of subconjunctival aqueous humor drainage tube without plate into anterior chamber (procedure)

Additional new concepts will be created to represent implantation procedures in other anatomical sites.

Please see this briefing note.

Update 274450004 |Dislocated shoulder reduction (procedure)| Hierarchy and Related Disorders.

The finding site for 'Dislocation of shoulder' is not currently aligned to the anatomic model for 'Joint of limb'. In common usage, 'shoulder joint' would usually refer to the glenohumeral joint. 

Related concepts stating the term 'Shoulder joint' will be modeled with 85537004 |Glenohumeral joint structure (body structure)| as target for the 363698007 |Finding site (attribute)| in Disorder concepts and for the << 363704007 |Procedure site (attribute)| in Procedure concepts.

Proposed Inactivation of <<443938003|Procedure carried out on subject (situation)|

Please see this briefing note.

Patches Strength Representation in Clinical Drugs

Please see this briefing note.

Update for Fetal Model and Inactivation of Non-Unique Fetal Part Structures

The concept model for fetal procedures and findings will be updated in the international edition of SNOMED CT. The model employs the attribute 246454002 |Occurrence (attribute)| with the value 303112003 |Fetal period (qualifier value)| and its subconcepts for modeling purposes. Finding and procedure sites will be revised to utilize canonical or morphological structures (excluding unique fetal structures) such as persistent or malformed structures.

For example, concepts modeled with site 'fetal head structure' will have site replaced by 'head structure' in combination with 'fetal period' occurrence.

Currently, there are 60 concepts within the international edition of SNOMED CT that are modeled using < 367570001|Fetal part (body structure)|. These concepts will be reviewed and revised. Once complete, 118 descendants of 367570001|Fetal part (body structure)| will be reviewed. Non-unique fetal parts, such as ‘fetal head’, will be inactivated from the anatomy hierarchy in a subsequent release.

National extensions should update the model for fetal findings and procedures to ensure consistent classification. If any subconcepts of 367570001|Fetal part (body structure)| are required for other use cases, please submit this information to info@snomed.org 

Inactivation of Surgical Domain in MRCM

The attribute 180593004 |Surgical approach (qualifier value)| has been inactivated and replaced by 116688005 |Procedure approach (attribute)|. There is no attribute that is specific to the surgical procedures anymore. This domain will be inactivated in the MRCM. The entries will be inactivated in the RF2 refset release file. These changes should not have any impact on existing concepts and modeling.

Review of 409793007|Antimicrobial resistant bacteria (organism)| and Descendants

409793007|Antimicrobial resistant bacteria (organism)| and descendants will be reviewed and content corrections made as appropriate.  The review will focus on:

• Aligning taxonomic lineages of resistant bacteria with those of bacterial (only) portions of the organisms hierarchy. Missing ranks including (and limited to) order, family, genus, species will be added as necessary.  Example:
• The lineage of beta-lactam resistant Escherichia coli, beta-lactam resistant Escherichia (genus), beta-lactam-resistant Enterobacteriaceae (family), beta-lactam-resistant Enterobacterales (order).  
• Aligning organisms that are said to be resistant with corresponding antimicrobial substances hierarchy.  Example: 
• Ampicillin < penicillin < beta-lactam
• Making the grammar and description style consistent throughout the hierarchy and compliant with the editorial style guide. The pattern “antimicrobial-resistant organism” will be maintained.  The antimicrobials themselves may be hyphenated.  
• Examples: Ampicillin-resistant Escherichia coli

Update for Existing AJCC (American Joint Committee on Cancer) Allowable Values and New UICC (Union for International Cancer Control) Staging System Content

For << 1222584008 |American Joint Committee on Cancer allowable value (qualifier value)| and its 584 subtypes the following changes will be made:

• Preferred Term (PT) will be inactivated and a new PT added that contains the existing AJCC code with a new parenthetical addition of AJCC: (AJCC).
• The existing text definition that contains the attribution to the AJCC Cancer Staging System, American College of Surgeons will be inactivated and re-created as an annotation.

New concepts for the UICC (Union for International Cancer Control) staging system will be added:

• As a separate hierarchy, approximately 580 new concepts for the Union for International Cancer Control (UICC) TNM staging system will be added. This work is being done under a collaboration agreement between SNOMED International and the UICC.

Changes to 365921005 | Weight change finding (finding) Hierarchy

Following multiple requests from members regarding overlaps and ambiguities in this hierarchy, the Nutrition and Dietetics Clinical Reference Group (CRG) conducted a systematic review. The requests highlighted confusion over similar and overlapping concepts, such as:

• 89362005 | Weight loss (finding) |
• 262285001 | Weight decreased (finding) |
• 161832001 | Weight decreasing (finding) |
• 426977000 | Recent weight loss (finding) |

The following changes will be implemented:

1. Inactivation of 426977000 | Recent weight loss (finding) | and 427572007 | Recent weight gain (finding)
   These terms are considered ambiguous due to the subjective nature of the word "recent."
2. Inactivation of 161832001 | Weight decreasing (finding) | and 161831008 | Weight increasing (finding)
   These terms will be inactivated because they do not align with editorial policy. They represent patterns or trends better handled by information models or statistical tools for data interpretation and analysis.
3. Inactivation of 89362005 | Weight loss (finding)
   This term is a duplicate of 262285001 | Weight decreased (finding) |. The term "Weight loss" will, however, remain as a synonym for 262285001.

Review Model for Descendants of 118240005|Finding by method (finding)|

Descendants of 118240005 |Finding by method (finding)| are currently being reviewed to ensure 418775008 |Finding method (attribute)| is appropriately grouped with other attributes.

Update for Description Concept Non-Current Indicators

Concept Non Current (CNC) indicators are a type of inactivation indicator that are applied to active descriptions, when the concept they are attached to is made inactive. They are intended to allow implementers to show some visual cue to alert users that a description they have searched for relates to an inactive concept.

A bulk update will be implemented to inactivate CNC indicators where they are no longer required either because:

• The concept has since been re-activated or,
• The description itself has now been inactivated

This will result in a change to approximately 30,000 descriptions for the international edition release for January 2025.

Restructure of 384760004 |Feeding and dietary regime (regime/therapy)| 

Following a review by the Nutrition and Dietetics Clinical Reference Group (CRG), in consultation with the Nursing CRG, a restructuring of this hierarchy is underway. The content will be reorganized more logically, identifying and addressing duplicate concepts (e.g. 414096000 |Enteral hyperalimentation (regime/therapy)| and 229912004 |Enteral feeding (regime/therapy)|) and removing outdated content (e.g. 37041007 |Forced feeding of patient (regime/therapy)|). Where possible, content will be sufficiently defined. 

Additionally, the top-level grouper concept 384760004 |Feeding and dietary regime (regime/therapy)| will be inactivated due to its ambiguity as it is unclear what a combined regime would represent or what the logical subtypes would be.  

Hierarchy Improvement 272185007 |Meters (physical object)| and Descendants

To support the addition of Gravity provision of device finding content, an improvement will be made to << 272185007 |Meters (physical object)|. 

MRCM change to Surgical approach (attribute)

• Phase 1: Move 116688005 |Procedure approach (attribute)| from the 408739003 |Unapproved attribute (attribute)| hierarchy to the 762705008 |Concept model object attribute (attribute)|. Add and test new MRCM rules for procedure approach. Make 424876005 |Surgical approach (attribute)| a subtype of 116688005 |Procedure approach (attribute)|. 

Malignant tumor of X - Update Descriptions

Disorder concepts with a current FSN of the pattern:

• Malignant tumor of <body site>
• Benign tumor of <body site>

Will have the existing FSN inactivated and replaced by:

• Malignant neoplasm of <body site>
• Benign neoplasm of <body site>

A synonym including the word 'tumor' will remain active.  This update will be made to approximately 500 concepts. 

New Substance Groupers for Anesthetics

Based on feedback from the Anesthesia Clinical Reference Group, the substance hierarchy for anesthetics will be reviewed and the hierarchy revised with additional groupers created and subtypes assigned for inhalation anesthetics (1354647001|Volatile liquid anesthetic (substance)) and local anesthetics (1354706009 |Benzoic acid ester local anesthetic (substance) and 1354705008| Amide local anesthetic (substance)).

Taxonomic relationship between 1149322001 |Intoxication (disorder)| and 75478009 |Poisoning (disorder)|

Based a query submitted by the Translation Working Group, the SNOMED CT current taxonomic relationship between 1149322001 |Intoxication (disorder)| and 75478009 |Poisoning (disorder)| (the former being a subtype the latter) requires further review. While they are related, both are defined as interference in normal bodily functions caused by exposure to a substance. Based on the severity of the consequences, the relationship is really the reverse: an intoxication is a milder reaction to a substance, while poisoning is more severe as noted in the definition.

The definition of 1149322001 |Intoxication (disorder)| will be updated to make the distinction between the two concepts more comparable. The current relationship between the two concepts will be reversed.   

MRCM Update <<540091010000105 |Calculation (calculation)|

The range for Component Attribute will be extended to Include <<540091010000105 |Calculation (calculation)|

New Semantic Tag - Calculation

A new semantic tag of (calculation) will be added as a descendant of (qualifier value). This will enable representation of concepts that are derived from calculations on other observations (e.g., “Anion gap in blood,”  “Anion gap in urine”) with a relationship of Component (attribute) and value from the (calculation) sub-hierarchy.

Update for Assessment Scale Score Concepts

Concepts that are subtypes of 363788007 |Clinical history/examination observable (observable entity)| that are assessment scores but are not also subtypes of 782487009 |Assessment score (observable entity)|, will gain a parent of 782487009 |Assessment score (observable entity)|.  Estimated 1300 concepts.  

Inactivation of Splinter of <x>, Without Major Open Wound Content

Concepts that represent splinters of <x>, without major open wound and splinters of <x>, without major open wound, infected, are classification constructs. These concepts are being inactivated with historical associations to the base concept e.g. Splinter of toe, without major open wound (disorder) will be inactivated as classification derived component with a historical association to Splinter of toe (disorder). The latter will be a new concept. Where required, new 'base' concepts will be created.  

Inactivation and Replacement of 284937000 |Ability to sit on toilet (observable entity)| and Related Finding Concepts

The concept 284937000 |Ability to sit on toilet (observable entity)| and the related finding concepts e.g. 284938005 |Able to sit on toilet (finding)| could be interpreted as relating to the ability to maintain a sitting position on a toilet seat or the ability to sit down on a toilet seat.

These concepts will be inactivated and replaced with new concepts

Ability to maintain sitting position on toilet seat (observable entity)

Ability to sit down on toilet seat (observable entity)

together with relevant finding concepts e.g. Able to maintain sitting position on toilet seat (finding). 

SNOMED CT to Orphanet Map - Attribution of In Scope Content

Work has commenced to annotate new concepts added to SNOMED CT with attribution to 'Inserm Orphanet'. As part of this effort, textual definitions for concepts previously added for this project will be updated to align with the current published version of the Orphanet definition. This will result in published text definitions being inactivated and replaced.

Inactivation of 80113008|Complication of the puerperium (disorder)|

80113008|Complication of the puerperium (disorder)| will be inactivated with historical association to 362973001|Disorder of puerperium (disorder)|. This change is being made to align with the Editorial Guide

These changes are being undertaken for this content tracker.

Updated terming and modeling of <392570002 |Blood pressure finding (finding)| (~50 concepts) Updated to 80 Concepts

Descendants of 392570002 |Blood pressure finding (finding)| which include 'decreased,' 'increased,' 'normal,' 'abnormal' etc. in the FSN will be updated as follows:

1) FSN will be changed to 'below reference range,' 'above reference range,' 'within reference range,' or ''outside reference range.'
2) Descriptions with 'decreased,' 'increased,' 'normal,' 'abnormal', etc. will be retained as acceptable synonyms.
3) Modeling of the Has interpretation (attribute) value will be updated to 281300000 |Below reference range (qualifier value)|, 281302008 |Above reference range (qualifier value)|, 281301001 |Within reference range (qualifier value)|, or 394844007 |Outside reference range (qualifier value)|.

Concepts inactivations are not expected during this work.

These changes are consistent with rationale from previous work in updating the measurement findings content. Please see the briefing note 20221103 BN Reference range measurement findings and the 'Measurement findings' section of the Editorial Guide.

Review of 42571002 |Failed induction of labor (disorder)| and Descendants

The following concepts will be inactivated and new concepts will be added to the situation with explicit context hierarchy as subtypes of 103709008 |Failed attempted procedure (situation)|

• 42571002 |Failed induction of labor (disorder)|
• 90188009 |Failed mechanical induction (disorder)|
• 77854008 |Failed medical induction of labor (disorder)|
• 91484005 |Failure of induction of labor by oxytocic drugs (disorder)|

Update to Attribute Cardinality

The following attributes used in modeling << 363787002 |Observable entity (observable entity) will have their cardinality updated from 0..1 to 0..*. The changes will support modeling observable entity concepts where two (or more) types of observations are modeled in one concept and the result is reported in one value.

• 370132008 |Scale type (attribute)| - PLANNED FOR JUNE 2025 RELEASE
• 370134009 |Time aspect (attribute)|
• 704323007 |Process duration (attribute)|
• 370130000 |Property (attribute)|
• 246514001 |Units (attribute)|

Remodel for 784289008|Nerve palsy (disorder)| and Inactivation of 255324009|Movement (observable entity)|

784289008|Nerve palsy (disorder)| will be remodeled to reflect a more generalized concept.  Current modeling limits descendants to be designated by "gross movements of body and limbs".  It will be generalized to movement in general to account for disorders such as facial palsy. This will result in a large number of concepts being moved directly under 784289008|Nerve palsy (disorder)|. 

255324009|Movement (observable entity)| will be inactivated with reason duplicate and historical association to 363847004|Movement observable (observable entity)|. 

Ten clinical finding concepts will be impacted by this change and be remodeled to reflect the appropriate supertypes.

Update for Enterocele Disorder and Procedure Content

398061002 |Vaginal enterocele (disorder)| and 302371001 |Repair of enterocele (procedure)| hierarchies will be reviewed to update the model for sex specific concepts.

“Enterocele” is currently a synonym of 398061002 |Vaginal enterocele (disorder)|. This is under review given that “Enterocele” may occur in both males and females. Additionally, this concept is modeled with a 363698007 |Finding site (attribute)| of 30315005 |Structure of small intestine (body structure)|, this will be updated because “Enterocele” may involve different portions of the intestinal structure.

The site of occurrence for enterocele is different for males and females, the site in males is 85481009 |Structure of rectovesical pouch (body structure)| while for females the site is 53843000 |Structure of rectouterine pouch (body structure).

Following the same logic, the current model for 302371001 |Repair of enterocele (procedure)| with 263355003 |Structure of vaginal wall (body structure)| as the value for the 405813007 |Procedure site - Direct (attribute)| will be reviewed.

Both hierarchies are under review to add sex specific enterocele disorders and repair of enterocele procedures, and to remodel the Finding site of the “Enterocele disorder” to a more generic 113276009 |Intestinal structure (body structure)|.

Disorders and Procedures - Subdural

Concepts using 'subdural' in their descriptions are being assessed to ensure the meaning in the descriptions is clear and the site specified aligns with the FSN. Further information can be found in this Content Tracker.

Update to Attribute Cardinality

The following attribute used in modeling << 363787002 |Observable entity (observable entity) will have cardinality updated from 0..1 to 0..*. The change will support modeling observable entity concepts where two (or more) types of observations are modeled in one concept and the result is reported in one value.

• 370132008 |Scale type (attribute)| 

Inactivation of Follow-up and Initial Assessment Procedure Concepts

Review Hierarchy 313214000 |History of abuse (situation)|  and Descendants

The sub-hierarchy << 313214000 |History of abuse (situation)| and suspected abuse concepts will be reviewed and content changes made as required, in relation to the role of the subject of the record as the victim or the perpetrator. To support this work, new finding concepts will be created as required.

Description Update for Bowen’s Disease

Bowen's disease related content will be updated to improve consistency for translation and to align these concepts with authoritative sources for neoplasms and editorial guidance regarding eponyms.

• 84999002 |Bowen's disease (morphologic abnormality)| will be inactivated and replaced by 1162893000 |Squamous cell carcinoma in situ (morphologic abnormality)|. Description naming patterns will be applied according to the |Finding site|.
• For concepts with a |Finding site| of skin structure, the following naming pattern will be applied:
  • FSN: Squamous cell carcinoma in situ of [body structure] (disorder)
  • PT: Squamous cell carcinoma in situ of [body structure]
  • SYN: Bowen disease of [body structure]
  • SYN: Bowen’s disease of [body structure]
  • SYN: Intraepidermal squamous cell carcinoma of [body site]
• For concepts with a |Finding site| other than skin structure, the following naming pattern will be applied:
  • FSN: Squamous cell carcinoma in situ of [body structure] (disorder)
  • PT: Squamous cell carcinoma in situ of [body structure]

Other related morphologic abnormality concepts will be reviewed by the Histology Quality Group as part of their ongoing activities.