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Please see the attached briefing note in relation to the inactivation of Clinical finding and Procedure concepts which include the context of subject or patient in the FSN. Prior to taking this step we are looking to determine the impact of this change on extension managers and users. This briefing note is being circulated to several groups including the CMAG.

Feedback should be provided via by no later than 31 March 2023. 

Relevant documents


Final outcome: 


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  1. Hi Cathy Richardson,

    Thank you for the briefing note. I think the examples mentioned in note are very well argumented for and will remove some very pre-coordinated descriptions. The examples are from the Clinical findings and Procedures only. Do you plan to change concepts from other hierarchies too, like for instance 105480006 |Procedure declined by patient (situation)| and if so how would you do this?


    1. Hi Camilla Wiberg Danielsen ,

      The focus hierarchies for this piece of work are the Clinical finding and Procedure hierarchies. Concepts in the Situation hierarchy can include explicit context in relation to whom the concept represents information about e.g., mother, subject of record. While concepts that express the meaning ‘patient’ such as 105480006 |Procedure declined by patient (situation)|, do not align with current guidance on the use of patient vs subject they are out of scope for this work.

      Kind regards,


  2. Hi Cathy Richardson,

    Thank you for the briefing note and examples. Would it be possible to see the analysis scripts (i.e. ECL and/or SQL) used to identify actionable content for this briefing note? I would like to perform a similar validation on content in the US extension to determine if any content needs to be evaluated for potential modification or inactivation.

    Regarding the question: Is there a need for concepts that explicitly include the meaning ‘subject’ or would the creation of a base concept meet requirements?

    In a situation where the FSN needs to explicitly state and/or included the meaning of 'subject', it would seem appropriate to require these concepts to be placed in the situation with explicit context hierarchy so that the content may be modeled with the explicit context constraint stated as part of the logical definition. This will help to prevent the misuse of the concepts within an information model that carries the context. (e.g. family history) Adding an entry to the Pre-coordinated naming pattern project with the general business rules surrounding this topic may be a helpful way for authors to quickly reference the information.

    1. Hi John Snyder ,

      The query used to identify this content was done using the Term contains X report in the SNOMED CT reporting platform. This report was used as the example on the Run an existing report page from the Authoring Platform User Guide: You will also find some further information at the topic of the report page within the reporting platform.

      Kind regards,


      1. Hi Cathy Richardson,

        I will have to check with managed services because I don't have access to the filter queries in the reporting platform. This must be restricted to international authors.

        Thank you for the information.


  3. Thank you for this- it makes absolute sense in most instances however there are a number of procedure concepts where the patient performs a procedure on themselves or a finding regarding a patient's self care ability. Will these be included in the rule?

    Is there a better way of modelling procedures and supervision of procedures where the patient performs the procedure? It appears that for most procedures there is an assumption that the procedure is performed by the clinician/care provider not the patient but cannot find any documentation to support this, so when we try to record that this is a procedure performed by the patient or a clinical finding concerning a patient's ability to perform a procedure modelling becomes problematic as the patient in this instance is the subject of the record and the object. This also creates an issue for us when trying to author procedures performed under supervision, where the person performing the procedure is the patient or caregiver but we would like to record that clinical supervision was undertaken- for example a COVID 19  rapid antigen test performed by the patient under supervision. Is there any way we could model this more consistently within the situation with explicit context hierarchy?

    1. Hi Elizabeth Tanya Antoun ,

      Guidance on how to model these concepts is in development. I will advise further when this has been completed. 

      Kind regards,


  4. Thank you for sharing this briefing note. Evaluating how this might impact Nutrition content, only 3 concepts were identified. Two of 3 seem clear without reference to the patient 

    25156005 |Intravenous feeding of patient (regime/therapy)|

    447951000124108 |Patient dissatisfied with nutrition regime (finding)|

    We would suggest considering inactivation of 61420007 |Tube feeding of patient (regime/therapy)| as a duplicate of its parent 229912004 |Enteral feeding (regime/therapy)|

    cc: Constantina Papoutsakis 

    1. Hi Donna Pertel ,

      Thank you for your comments in relation to the nutrition content. 

      Kind regards,


  5. Thank you for the feedback comments made to date. I will look to respond to the questions shortly. 

  6. Hi all,

    Thank you for the feedback provided. 

    In progressing this topic we are looking to ascertain the requirement/ clinical use case at the international level for documentation of procedures where the procedure is undertaken by someone other than a health professional e.g. a subject of care or caregiver. We have noted this is a requirement for New Zealand Elizabeth Tanya Antoun Is this a requirement in other countries as well?  Feedback on this question should be provided by 22nd May 2023.



  7. Hi Cathy,

    It is our feeling that the need for documentation of procedures undertaken by someone other than health professionals can be relevant as more and more care is being transfered to the patients own home and therefore will be handled by the patient or next of kin. We are also interested in how this can be modeled in SNOMED CT.

  8. The question is whether the performer of the procedure should be pre-coordinated with the type of procedure itself.  In the majority of procedures, the type of performer is not specified although the qualifications can be highly variable.  examples include Medical doctor vs. nurse practitioner, psychiatrist vs clinical psychologist vs. social worker, anesthesiologist vs. nurse anesthetist.  I would think that the person responsible for performing the procedure would be recorded as a separate element within the medical record.  Although all of my examples are types of health professionals, they differ in their levels of "expertise", which may be relevant in cases of adverse events, yet we do not record that as pre-coordinated content.  Location of where the procedure is performed is another aspect that should probably be recorded as a separate element.  The potential combinatorial explosion of pre-coordinating the actual procedure with the performed and the location would not be feasible to create or maintain.