Terminology Committee SNOMED CT Concept request form - November 2012
Request for Diagnostic Terms
Rare Disease Groups & for the Practice of Renal Medicine in the UK
Ver07
This form should be used to request a new SNOMED CT term and code. This may be required for a
Rare Disease Group project but this form may also be used to request help in generating
diagnostic terms and their correct codes for any other research, clinical, educational or service
development project. Use a new form for each term required.
Before completing the form, it is worthwhile checking the current version of SNOMED CT because
the term needed may already exist. In that case you only need to send this request if you want the
term displayed as part of a subset or pick list for a RADAR or RPV project. In that case, as well as
including the term you need in drop down lists etc., we may ask you to provide further expert
information about the disorder so that the correct semantic links can be created. The reason for
this is explained below.
Instructions about installing the free CliniClue SNOMED CT browser and the current version of the
SNOMED CT data on your PC and how to access SMONED CT on a website are available on the
Renal Association website at:
http://www.renal.org/Libraries/Terminology_Committee/CliniClue_installation_guide_October_2012.sflb.a
shx.
It may be useful to discuss the question with the Chair of the Terminology Committee or
intentionally to submit an incomplete form to stimulate discussion.
In either instance or to submit a completed form, please contact the Chair, Dr Afzal Chaudhry, at
anc35@cam.ac.uk, tel: 01223-331774.
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Terminology Committee SNOMED CT Concept request form - November 2012
REQUEST FORM - NEW SNOMED CT DIAGNOSIS CONCEPT
Questions:
1)
1a)
Describe the thing which you want to record using a structured SNOMED CT term.
This could be but is not limited to a disease, diagnosis, syndrome, symptom, clinical finding,
procedure or outcome. Professional terminologists will use this information to generate the
‘Fully Specified Name’ of the concept. That is intended to avoid ambiguity but it is still
possible and indeed often desirable to use more familiar synonymous terms in daily practice.
However, it is essential that the concept is described clearly and fully at this stage.
1b) Provide the ONE ‘Preferred term’ that you wish to be used for this concept.
This can be a more familiar term often used in daily clinical practice.
1c)
List those terms that that you wish to be used as a SYNONYM for this concept.
These should be commonly used terms to represent the same concept other than the ‘Fully
Specified Name’ and ‘Preferred term’. A narrower or broader synonym should be considered
as an error.
1d)
List any abbreviations, eponyms, pet names and anything else that might be useful as a
search key.
This need not imply that the term is correct or even approved – it just has to be useful. For
example, the term 'MI' might be useful to find 'myocardial infarction', 'mitral regurgitation
(mitral incompetence)', and if BG' were entered, it might be useful to offer both 'blood
glucose' and 'arterial blood gas' even if 'BG' is not an approved term for either. Once the
user has selected the correct term, it can be saved and displayed in a non-ambiguous way in
the clinical record.
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Terminology Committee SNOMED CT Concept request form - November 2012
REQUEST FORM - NEW SNOMED CT DIAGNOSIS CONCEPT
Questions:
2)
SNOMED CT can cope with any level of granularity. For specialist and research work, it is
usually important to specify a high level of granularity i.e. including of all the technical
details. In order to provide the correct context for very granular terms, it is useful to identify
the parent term that already exists and then to consider whether your new term will make
more sense if you add some other intermediate granularity terms for similar specialised
conditions that could exist under the parent term you have identified, even if you do not
have any particular interest in them. When your new term is used, the presence of these
other terms in the coding scheme makes it clear that the user has chosen your term in
preference to the other available terms and did not use your term inappropriately when
they were unable to find anything better and did not want to use a very general ‘parent’
term (which is what they should do if an appropriate granular term does not exist).
For example, suppose you want to describe a dark blue diesel Ford Fiesta Econetic but you
find the coding scheme only offers ‘Modes of transport’. You might then ask for some
medium granularity terms to be generated to set the scene e.g. land, air, and sea transport.
Then under ‘land’ you might want trains, buses and cars etc.
2a)
Do you need help to search for existing terms?
2b)
Do you need any new terms of ‘intermediate granularity’ to set the scene for the new
terms that you plan to use?
Yes / No (delete as appropriate)
Yes / No (delete as appropriate)
Page 3 of 8
Terminology Committee SNOMED CT Concept request form - November 2012
REQUEST FORM - NEW SNOMED CT DIAGNOSIS CONCEPT
Questions:
3)
If you are aware of any reference to the topic in an existing coding or terminology system,
please give as much information as possible e.g. an existing SNOMED CT term, the
International Classification of Diseases (ICD), a specialty specific coding scheme or a clinical
scoring scheme.
4)
Please give references or web links to literature that will help the terminology group to
understand the background to your term.
5)
If an agreed definition of the term you are requesting already exists, please give references
and URLs (as appropriate).
6)
If you are aware of any points of possible confusion or contention, please highlight them
here.
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Terminology Committee SNOMED CT Concept request form - November 2012
REQUEST FORM - NEW SNOMED CT DIAGNOSIS CONCEPT
Questions:
7)
SNOMED CT allows the meaning of clinical terms to be stored as well as the words. Provided
that the concepts have been correctly interpreted, it does not matter which words,
abbreviations, eponyms or even language are used to enter the data or to search databases.
Obviously this can only work if knowledgeable experts control the initial registration of new
terms and specify their meaning and context. This is referred to as the 'semantic links'.
It is impossible to ask sensible questions that will elicit all of the correct semantic links for
each and every concept which have not yet been properly defined so the questions below
are just to give you an idea of what is required. The aim is to allow future users to capitalise
on the ability of a SNOMED CT browser to generate a ‘mind map’ showing the logical links
which will enable someone to find all the things with which your term is associated and to
arrive at your term by following logical links from all the related terms.
A useful way to do this is to answer the questions below.
Examining the map for renal vein thrombosis at:
http://www.renal.org/Libraries/Terminology_Committee/RVT_Is_A_mindmap_SNOMED_CT
_2012.sflb.ashx
may clarify what is required but remember if you are describing a new situation, you may
need to work out new questions. Please discuss this with the Terminology Committee which
has access to professional terminologists with specialist training in this work. Getting this
right often requires a few iterative cycles with discussion between medical and scientific
experts and terminologists.
With reference to your proposed term can you describe it using any of the headings
below?
Make as many entries as you can in response to each statement. If you are an expert and
know that the information does not exist, please enter N/A. If you personally do not know
please enter ‘?’. If you can suggest other headings or questions, the answers to which will
clarify the position, please add them below.
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Terminology Committee SNOMED CT Concept request form - November 2012
REQUEST FORM - NEW SNOMED CT DIAGNOSIS CONCEPT
Questions:
With respect to the new term and for all recognised (even if not well defined / described)
phenotypes please provide information under the following headings with as much granularity /
detail as possible.
7a)
FINDING SITE:
This specifies the body site affected by a condition, e.g. kidney structure.
7b)
ASSOCIATED MORPHOLOGY:
This specifies the morphologic changes seen at the tissue or cellular level that are
characteristic features of a disease, e.g. splitting of the glomerular basement membrane.
Note this is the place to make sure that the diagnostic histopathological features are
properly represented in SNOMED CT.
7c)
ASSOCIATED WITH:
This asserts an interaction between two concepts beyond simple co-occurrence in a patient.
This attribute does not assert or exclude a causal or sequential relationship between the two
concepts, e.g. associated with systemic disease.
CAUSATIVE AGENT:
identifies the direct causative agent of a disease, e.g. organism,
substance
DUE TO:
relate a finding directly to its cause.
AFTER:
a clinical finding occurs after another clinical finding or procedure.
This attribute emphasis a sequence of events without asserting or
excluding a causal relationship. e.g. perinephric haematoma after a
renal biopsy; staphylococcal bacteraemia after insertion of a central
venous catheter
7d)
CLINICAL COURSE:
This represents both the course and onset of a disease, e.g. chronic.
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Terminology Committee SNOMED CT Concept request form - November 2012
REQUEST FORM - NEW SNOMED CT DIAGNOSIS CONCEPT
Questions:
7e)
PATHOLOGICAL PROCESS:
This represents the underlying pathological process which is not covered by associated
morphology, e.g. infectious process.
7f)
HAS DEFINITIONAL MANIFESTATION:
This represents the manifestation which defines the disorder, e.g. immune system finding. If
the disorder has been formally defined, this is where to state it.
7g)
OCCURRENCE:
This refers to the specific period of life during which a condition first presents, e.g.
childhood.
7h)
FINDING METHOD:
This specifies the means by which a clinical finding is determined e.g. immunofluorescence
microscopy; renal biopsy.
7i)
FINDING INFORMER:
This describes the person or other entity e.g. Rare Disease Group from which the clinical
finding information is obtained. This attribute is frequently used in conjunction with FINDING
METHOD.
Page 7 of 8
Terminology Committee SNOMED CT Concept request form - November 2012
REQUEST FORM - NEW SNOMED CT DIAGNOSIS CONCEPT
Questions:
8)
Do you know if patients to whom this term may be applicable may be referred to other
specialties?
This information may help us to identify an appropriate terminology expert.
9)
If the answers to any of the above questions contain information that should not be in the
public domain until research work has been published, please clarify the exact position
here.
To submit a completed form, please return to the Chair of the Terminology Committee
Dr Afzal Chaudhry
Email: anc35@cam.ac.uk
-o0o-
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