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Data Entry ContextConstraints on ValuesInterpretation of Recorded Data
Initial diagnosis on an encounter or admission form

A concept recorded in this data entry context should be a subtype of

Concept
t64572001 Disease (disorder)
.

Info
iconfalse
titleExample

A healthcare professional assesses an unconscious person in the emergency room and concludes that the patient is suffering from effects of alcohol. To enter this initial diagnosis they type "alcohol".

An unconstrained search for "alcohol" will find a concept with the term

Concept
ShowPartsterm
t53041004 Alcohol
and may show that at the top of a search list. The problem is that this term is a synonym for the
Concept
t53041004 Alcohol (substance)
. While a substance may be relevant to the patient's condition a substance is not a valid diagnosis.

A search for the term ""alcohol" constrained to subtypes of

Concept
t64572001 Disease (disorder)
avoids this error and results a shorter, more appropriate list including concepts such as
Concept
t25702006 Alcohol intoxication
.


The fact that this is an "Initial diagnosis" data entry context needs to be captured so that the record can be appropriately interpreted.

Info
iconfalse
titleNote

Subsequent investigations and assessments may refute the initial diagnosis. In this case, the initial diagnosis should not be presented as a condition the patient has actually had. However, it may remain relevant as the rationale for initial treatment and investigation. Furthermore, a subsequently refuted initial diagnosis may also be of interest from the perspective or service administration, clinical audit and research.


Surgical history as part of past medical history

A concept recorded in this data entry context could either be:

  • A subtype of
    Concept
    t161615003 History of surgery (situation)
    ; or
  • A subtype of
    Concept
    t387713003 Surgical procedure (procedure)
    with an indication that this is past history.
Info
iconfalse
titleExample

A past history of an appendectomy could be recorded in different ways including:

  • Using the concept
    Concept
    t428251008 history of appendectomy
    ; or
  • Using the concept
    Concept
    t80146002 appendectomy
    with an indication that this was reported by the patient as having been done in the past.


The "Past History" data entry context needs to be captured so that the record can be appropriately interpreted. It must be possible to distinguish a past history record of a procedure from a contemporaneous record of the same procedure.


Info
iconfalse
titleNote

The definitions of concepts that are subtypes of

Concept
t161615003 History of surgery (situation)
formally represent the past history context by including the attribute
Concept
t408731000 |Temporal context| = 410513005 |In the past|
. If subtypes of
Concept
t387713003 Surgical procedure (procedure)
are to be used to record surgical history, these record entries must include an explicit indication of the past history context.

In either case, it may also be useful to indicate the source of the information (e.g. reported by patient, derived from original record) and actual or approximate date of the procedure.


Symptom check list with yes or no options for each symptom

Each question should be bound to a concept that represents the relevant symptom. These concepts should be subtypes of

Glossconcept
t404684003 Clinical finding
.

The simplest way to represent the "yes" and "no" answers to a question like this is to record the relevant finding concept if the answer is "yes" and not to create a record if the answer is "no". However, where the answer "no" has clinical significance, alternative approaches discussed in the next column may be preferable.

Info
iconfalse
titleExample

A question about whether a patient has a sore throat would be linked to the concept

Concept
t162397003 sore throat
.

  • If the patient answers "yes" then
    Concept
    t162397003 sore throat
    is added to the patient's record.
  • If the patient answers "no" then no entry is added to the record (see notes on alternatives in next column).


The simple approach suggested in the previous column does not explicitly record negative answers. However, in many cases, a negative response has its own significance and does need to be recorded.

  • For example, knowing that the patient responded "no" to the question "have you had any pain in the chest?".

Similarly, there may be questions that have 3 alternative answers (e.g. "yes", "no", "don't know"). In these cases an approach is needed to distinguish between the available responses.

Info
iconfalse
titleNote

Options for representing answers such as "yes", "no" and "don't know" include:

  1. A
    Gloss
    tpostcoordinated expression
    using the SNOMED CT situation with explicit context model
    Footnote ref
    with the symptom represented as the
    Concept
    t246090004 Associated finding
    and the answers represented as values of the
    Concept
    t408729009 finding context
    attribute (e.g "yes" =
    Gloss
    t410515003 known present
    , "no" =
    Gloss
    t410516002 known absent
    and "don't know" =
    Gloss
    t261665006 unknown
    .
  2. A simplified representation of the situation model in which only the finding context values are recorded - e.g. "yes" =
    Gloss
    t410515003 known present
    , "no" =
    Gloss
    t410516002 known absent
    and "don't know" =
    Gloss
    t261665006 unknown
    .
  3. A simplified representation of the situation model in which the associated finding is used for "yes" and the finding context is used for "no" and "don't know". For example, "Yes" =
    Concept
    t162397003 sore throat
    , "no" =
    Gloss
    t410516002 known absent
    and "don't know" =
    Gloss
    t261665006 unknown
    .


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