Creation of a local interface terminology to SNOMED CT.
2007; National Institutes of Health; Volume: 129; Issue: Pt 1 Linguagem: Inglês
Autores
Alejandro López Osornio, Daniel Luna, María Laura Gambarte, Adrián Gómez, Guillermo Reynoso, Fernán Gónzalez Bernaldo de Quirós,
Tópico(s)Electronic Health Records Systems
ResumoThis paper describes the steps followed in the creation of a local Interface Terminology to SNOMED CT (as reference terminology) with a strong focus on user acceptability. The resulting list of terms is used for clinical data input by physicians and nurses at the Hospital Italiano in Buenos Aires, Argentina. Description includes data model, mappings to SNOMED CT and classifications, subsets definitions and extensibility mechanisms. The Interface Terminology is currently used in the recording of diagnosis and procedures in inpatient discharge summaries and its coverage is improving from user feedback. Its current size is 24,800 concepts, 67% of them needed post-coordination for appropriate semantic representation, due to a very flexible policy that allows the use of any number of modifiers on concepts.
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