• Identifies terminology services required to support the design of data entry templates that facilitate entry of appropriate concepts into electronic health records.


This section identifies terminology services required to support the design of data entry forms and templates that incorporate . The objective of these templates is to facilitate the entry of appropriate  (or ) into electronic health records. 

As noted in the previous section, there are a variety of different EHR data entry contexts and each context logically constrains the range of  that can be used. This logical constraint can be formally specified using a  represented as an . Similarly, the data entry context may affect the meaning of data entered and this can be formally specified using a  represented by an  or .

A well designed template can simplify data entry and improve data quality by limiting the range of concepts available to those appropriate to a particular data entry context.  provides examples of some practical uses of templates with terminology bindings. 

Data entry templates can also be used to combine and structure related data items, or to enable addition of refinements a selected concept. Different requirements can be met by a common template structure with different . In other cases, a more complex template may be required containing a collection of data items with different . Similarly, a  may be applied to an individual template or to a collection of templates that share a similar interpretation (e.g. past medical history entries). Terminology bound templates that are designed to meet the needs of different data entry contexts can be combined into a more complex template that supports a complete data entry scenario.



Practical Uses of Terminology Binding in a Data Entry Template


Practical UseExamples
To specify a concept or expression to that is added to the record entry when a particular data entry option is selected
  • To specify that the concept should be added to record entry when an item in a check list of medical conditions is marked as true.
To constrain the range of concepts that can be entered into a specific data entry field
  • To limit the range of concepts that can be entered in "surgical procedure" field to:
    • Subtypes of ; or
    • Members of a locally defined reference set containing surgical procedures carried out in particular department.
  • To specify the concepts to be displayed in a short drop-down list from which an item may be selected.

To support the structured entry of specific refinements relevant to a selected concept

  • To specify a template that includes questions about general findings followed by prompts for the site of the finding and/or other features.
    • The template also specifies how the refinement should be represented. Options include:
      • A record containing several named data items { symptom: location: } ; or
      • An such as:


To support the entry of any refinement permitted by the concept model (or a constrained version of the concept model)
  • To specify a template that allows a clinical finding to be refined using any attributes that are valid in the clinical finding concept model.
    • The refined concept would be represented as an .


 shows a summary of the terminology services required to enable  to be created and edited when developing user interface templates for health record data entry.

Services Required for EHR User Interface Template Editing


Practical Requirement

Status

Required Terminology Services

Additional Terminology Service Dependencies

Select the SNOMED CT edition and version to be used.

4.1 Select Edition and VersionN/A
Create or edit a user interface template or control that records specific concepts in EHR depending on user selections

4.8 Find Concepts

N/A
Create or edit a user interface template including expression constraints that limit permitted values that can be entered through a specific data entry control

4.7 Validate and Apply Expression ConstraintsN/A
Create or edit a user interface template or control that records a specific expression in an EHR depending on user selections (in cases where no specific concept matches the required meaning)

4.14 Validate Concept Definitions and ExpressionsN/A
Get attributes that can be applied to an identified concept

4.13 Get Concept Model RulesN/A
Get the range of values that can be applied to an identified attribute

4.13 Get Concept Model RulesN/A


  1. Applications designed to address this use case must support the practical requirements marked as Required. Support for the practical requirements marked as Optional is recommended as these provide enhanced functionality that may be required by some users.
  2. In most cases, a reference to a subsection of 4 Terminology Service Types, implies a requirement for all services marked as Required in that subsection. However, where a reference is followed by a bulleted list, that list specifies the specific terminology services required. Some of the specific services listed as required for an Optional practical requirement may be marked as Recommended in the referenced subsection.
  3. The Additional Terminology Service Dependencies column contains references to services on which a Required Terminology Service depends. This column does not restate dependencies on services listed as required service or additional dependencies for essential requirements listed in earlier rows. A full list of the dependencies of each terminology service is provided in the relevant subsection of 4 Terminology Service Types.