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The first step in delivering comprehensive care is to undertake a clinical assessment. Clinical assessment data which can be recorded using SNOMED CT includes:

These data elements are described below, with example SNOMED CT subsets for each.

2.3.1 Symptoms 

Symptoms represent physical or mental features which are regarded as an indication of a condition or disease, particularly those features that are apparent to the patient. This SNOMED CT subset of COVID-19 symptoms has been developed based on a review of relevant Pubmed literature. 1, and research performed by Kings College London 2 

CV19-ASS-Symptoms
Concept idFully Specified Nameen-US Preferred TermEffective Time
29857009Chest pain (finding)Chest pain20040731
43724002Chill (finding)Chill20020131
49727002Cough (finding)Cough20020131
62315008Diarrhea (finding)Diarrhea20020131
267036007Dyspnea (finding)Dyspnea20020131
271807003Eruption of skin (disorder)Eruption of skin20020731
84229001Fatigue (finding)Fatigue20020131
386661006Fever (finding)Fever20030131
25064002Headache (finding)Headache20100131
66857006Hemoptysis (finding)Hemoptysis20020131
44169009Loss of sense of smell (finding)Loss of sense of smell20200131
36955009Loss of taste (finding)Loss of taste20020131
367391008Malaise (finding)Malaise20020131
68962001Muscle pain (finding)Muscle pain20020131
162397003Pain in throat (finding)Pain in throat20020131

2.3.2 Severity 

Severity represents the quality of the condition - for example,  24484000 | Severe (severity modifier) (qualifier value)| . Severity may be recorded for each symptom, or as a general statement of their disease state. 

CV19-ASS-Severity
Concept idFully Specified Nameen-US Preferred TermEffective Time
255604002Mild (qualifier value)Mild20020131
6736007Moderate (severity modifier) (qualifier value)Moderate20020131
24484000Severe (severity modifier) (qualifier value)Severe20020131
442452003Life threatening severity (qualifier value)Life threatening severity20090731

2.3.3 Clinical Measurements 

Clinical measurements involve the performance of physiological tests to diagnose and refine therapeutic management of an already established disease. The following clinical measurements can be used in the assessment of a COVID-19 patient.

CV19-ASS-ClinicalMeasurements
Concept idFully Specified Nameen-US Preferred TermEffective Time
386725007Body temperature (observable entity)Body temperature20170131
75367002Blood pressure (observable entity)Blood pressure20170131
364075005Heart rate (observable entity)Heart rate20170131
431314004Peripheral oxygen saturation (observable entity)Oxygen saturation (SpO2)20080731
86290005Respiratory rate (observable entity)Respiratory rate20170131

2.3.4 Clinical Findings 

Clinical findings are the result of measuring, questioning, evaluating, or otherwise observing a patient or a specimen from a patient in healthcare. The following clinical findings are positive or negative indications that signs are present in a COVID-19 patient.

CV19-ASS-ClinicalFindings
Concept idFully Specified Nameen-US Preferred TermEffective Time
371632003Coma (disorder)Coma20020731
193894004Conjunctival hyperemia (finding)Conjunctival hyperemia20100131
267036007Dyspnea (finding)Dyspnea20020131
126664009Exudative pharyngitis (disorder)Exudative pharyngitis20020131
442646005Imaging of lung abnormal (finding)Imaging of lung abnormal20090731
274710003Lung field abnormal (finding)Lung field abnormal20020131
91175000Seizure (finding)Seizure20020131
271823003Tachypnea (finding)Tachypnea20020131

Please refer to 2.1.1 Extension Concepts - Provider and Facility Details for a list of known extension concepts.

2.3.5 Diagnosis 

A diagnosis is the identification of the nature of the illness, based on an examination of the symptoms, observations, measurements, test results and other investigation results. The following subset includes a range of diagnoses directly related to COVID-19.

CV19-ASS-Diagnosis
Concept idFully Specified Nameen-US Preferred TermEffective Time
840539006Disease caused by severe acute respiratory syndrome coronavirus 2 (disorder)COVID-1920200131
840544004Suspected disease caused by severe acute respiratory coronavirus 2 (situation)Suspected COVID-1920200131
189486241000119100Asymptomatic severe acute respiratory syndrome coronavirus 2 infection (finding)Asymptomatic SARS-CoV-220200731
688232241000119100Disease caused by severe acute respiratory syndrome coronavirus 2 absent (situation)Disease caused by severe acute respiratory syndrome coronavirus 2 absent 20200731


Please refer to 2.3.1 Extension Concepts - Clinical Assessment for a list of known extension concepts.

2.3.6 Clinical History 

The clinical history concepts are used to record information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information, with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient.

CV19-ASS-ClinicalHistory
Concept idFully Specified Nameen-US Preferred TermEffective Time

292508471000119105

History of disease caused by severe acute respiratory syndrome coronavirus 2 (situation)

History of SARS-CoV-2

20200731

2.3.7 Complications 

A complication is a secondary disease or condition that aggravates the main condition (in this case COVID-19). This following subset includes clinical findings that are known to be potential complications of COVID-19. 

CV19-ASS-Complications
Concept idFully Specified Nameen-US Preferred TermEffective Time
373895009Acute respiratory distress (finding)Acute respiratory distress20020731
67782005 Acute respiratory distress syndrome (disorder)Acute respiratory distress syndrome20020131
419620001Death (event)Death20060131
308906005Secondary bacterial pneumonia (disorder)Secondary bacterial pneumonia20160131
75570004Viral pneumonia (disorder)Viral pneumonia20130731

138389411000119105

Acute bronchitis caused by severe acute respiratory syndrome coronavirus 2 (disorder)

Acute bronchitis caused by SARS-CoV-220200731
674814021000119106

Acute respiratory distress syndrome caused by severe acute respiratory syndrome coronavirus 2 (disorder)

Acute respiratory distress syndrome caused by SARS-CoV-2

20200731

880529761000119102

Lower respiratory infection caused by severe acute respiratory syndrome coronavirus 2 (disorder)

Lower respiratory infection caused by SARS-CoV-2

20200731
866151004Lymphocytopenia associated with severe acute respiratory syndrome coronavirus 2 (disorder)Lymphocytopenia associated with severe acute respiratory syndrome coronavirus 220200731

882784691000119100

Pneumonia caused by severe acute respiratory syndrome coronavirus 2 (disorder)

Pneumonia caused by SARS-CoV-2

20200731

866152006

Thrombocytopenia associated with severe acute respiratory syndrome coronavirus 2 (disorder)Thrombocytopenia associated with severe acute respiratory syndrome coronavirus 220200731


Please refer to 2.3.1 Extension Concepts - Clinical Assessment for a list of known extension concepts.

2.3.8 Exposure Event 

An exposure event is when an individual comes into close contact with an infected person's contaminated droplets, carried in the air or on contaminated hands, surfaces or other objects. The subset below includes SNOMED CT events for recording exposure to COVID-19.

CV19-ASS-ExposureEvent
Concept idFully Specified Nameen-US Preferred TermEffective Time
840546002Exposure to severe acute respiratory syndrome coronavirus 2 (event)Exposure to SARS-CoV-220200131

Please refer to 2.3.1 Extension Concepts - Clinical Assessment for a list of known extension concepts.

2.3.9 Known Risk Factors 

Know risk factors are used to record the known patient conditions which may increase the risk of the patient being especially vulnarable to the COVID-19 virus. The following clinical findings are known risk factors of COVID-19 3 4.

CV19-ASS-KnownRiskFactors
Concept idFully Specified Nameen-US Preferred TermEffective Time
195967001Asthma (disorder)Bronchial hypersensitivity20040731

78648007

At risk for infection (finding)

At risk for infection

20020131
27624003Chronic disease (disorder)Chronic disease20020131
413834006Chronic disease of immune function (disorder)Chronic disease of immune function20050131
17097001Chronic disease of respiratory system (disorder)Chronic respiratory system disease20020131
128238001Chronic heart disease (disorder)Chronic disorder of heart20020131
709044004Chronic kidney disease (disorder)Chronic kidney disease20150731
328383001Chronic liver disease (disorder)Chronic liver disease20090731

128283000

Chronic nervous system disorder (disorder)

Chronic nervous system disorder

20020131
13645005Chronic obstructive lung disease (disorder)Chronic obstructive lung disease20020131
13213009Congenital heart disease (disorder)CHD - Congenital heart disease20030731
73211009Diabetes mellitus (disorder)Diabetes mellitus20020131
8517006Ex-smoker (finding)Ex-smoker20020131
38341003Hypertensive disorder, systemic arterial (disorder)Hypertensive disorder20020131

234532001

Immunodeficiency disorder (disorder)

Immunodeficiency disorder

20020131
38013005Immunosuppression (finding)Immunosuppression20020131
414915002Obese (finding)Obese20050131
77386006Pregnant (finding)Pregnant20020131
6383007Premature labor (finding)Premature labor20020131
77176002Smoker (finding)Smoker20020131

2.3.10 Comorbidities 

Comorbidities are additional medical conditions of concern. The following SNOMED CT subset can be used to record comorbidities.

CV19-ASS-Comorbidities

Intensional Definition:

Intensional Definition:

404684003 |Clinical finding (finding)|  MINUS <  307824009 |Administrative statuses (finding)|

2.3.11 Covid-19 and Viral Co-Infections 

The following organism should be used when recording the organism causing COVID-19 infections.

CV19-ASS-Organism
Concept idFully Specified Nameen-US Preferred TermEffective Time
840533007Severe acute respiratory syndrome coronavirus 2 (organism)SARS-CoV-220200131

The following organisms can be used to record the cause of related viral co-infections.

CV19-ASS-ViralCoInfections



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