Figure 1
Percentage of exact matches and synonyms found in SNOMED CT® for the chart audit terms grouped under the relevant areas of health care focus.
Figure 2
Evaluation of the controlled vocabulary (n=12).
Table 1
Sample of multidimensional health factors that contribute towards an MCS patient profile grouped by the frequency of occurrence in the 100 patient charts
| Sample of frequently used terms (n=100) | Area of health focus | Frequency of occurrence |
|---|---|---|
| Fatigue | Medical, physical | 96% |
| Light-headedness | Medical | 93% |
| Sinus congestion | Medical | 89% |
| Light sensitivity | Medical | 89% |
| Food sensitivity | Nutrition | 75% |
| Poor memory/concentration | Nursing | 75% |
| Pain | Nursing | 73% |
| Poor balance | Physical | 72% |
| Withdrawn | Psychosocial | 65% |
| Bloating | Nutrition | 63% |
| Not working | Rehabilitation | 60% |
| Childhood abuse | Psychosocial | 52% |
| Schooling problems | Rehabilitation | 45% |
Table 2
Standardization of multidisciplinary terminologies using SNOMED CT®
| Discipline of care | Source terms | Terms from SNOMED CT® SNOMED CT ID, parent concept and synonyms |
|---|---|---|
| Medical | • Fatigue, tired, low energy | Fatigue – 84229001 (finding) Parents: energy and stamina finding General problem and/or complaint (finding) |
| • Cold extremities | Cold extremities (finding) – 15336001 Parent: temperature change at anatomical site (finding) | |
| • Fibromyalgia, FM, myalgia encephalitis | Fibryomyositis – 24693007 (disorder) Synonyms: fibromyalgia, myofascial pain syndrome Parent: myositis | |
| Nutrition | • Bloating, feeling bloated | Bloating symptom (finding) 248490000 Parent: finding reported by subject or history provider (finding) Swollen abdomen (finding) |
| • Food sensitivity, food intolerance, sensitivity to food | Propensity to adverse reactions to food 418471000 Parent: propensity to adverse reaction to substance (disorder) Synonym: food sensitivity | |
| Psychosocial | • Withdraw, withdrawn | Withdrawn (finding) 247755007 Parent: finding of level of interest (finding) |
| • Childhood abuse, trauma in childhood related to abuse | Victim of child abuse (finding) 397940009 Synonym – child abuse | |
| • Feels angry, anger, angry | Feeling angry (finding) 75408008 Parent: mood finding Synonym: anger |
Table 3
Standardization of multidisciplinary terminologies using SNOMED CT®
| Discipline of care | Source terms | Terms from SNOMED CT® |
|---|---|---|
| Nursing | • Clutter in house, clutter | Cluttered living space (finding) 424661000 Parent: finding of characteristics of home environment (finding) |
| Physiotherapy | • Low energy, lack of energy, very tired | Fatigue (finding) 22496004 Parent: energy or stamina finding (finding) |
| • Poor balance, balance impairment, balance | Poor balance (finding) 249985001 Parent: finding of general balance (finding) Impairment of balance (finding) | |
| Rehabilitation | • Out of work | Unemployed (finding) 73438004 Parent: social context (finding) Stopped work (finding) Synonym: out of work, without employment |
| • Schooling problems | School problem (finding) 161155000 Parent: social problem finding Synonym: school difficulties |
Table 4
Post co-ordination of missing terms in SNOMED CT®
| Source terms on MCS | Normalized term | Post co-ordination |
|---|---|---|
| Multiple chemical sensitivity (disorder) | Chemical; multiple; senstivity | 281867008|Multisystem Disorder|: {47429007|associated with|=35209006|sensitivity|: 410658008|triggered by|=441900009|chemical| 276339004|environment|} |
| Heightened sensitivity to environment (clinical finding) | Environment; heightened; sensitivity | 35209006|sensitivity|: {37135001|tolerance related finding|=260365005|heightened|: 44190009|triggered by|=276339004|environment|} |