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Status:
Implemented and live
Category:
Clinical documentation
Description
An all-Wales web-based platform with SNOMED CT supporting the recording of diagnostic and problem lists with treatment, medication and procedural information. Currently over 20,000 patients recorded and 147,891 clinical encounters since 2009.
Scope
An all-Wales platform accessible to users across Wales supporting the care of patients with a range of predominantly neurological conditions.
How SNOMED CT will be used
SNOMED CT has been used since 2009 since the system was installed. SNOMED CT is used to populate pick-lists such as ethnic origin or clinical findings, and to support rapid free-text data entry with terms matched as-you-type into SNOMED CT.
In addition, based on a range of generic and disease-specific rating scales, SNOMED CT terms are auto-entered. The UK edition and the dictionary of medicines and devices (DM&D) used to ensure terms are appropriate to a local UK audience and to include drugs and devices used within the UK.
SNOMED CT provides semantic knowledge so that for example, the software makes configuration changes based on an understanding of the specified diagnoses. For example, different options and screens will be shown for patients with multiple sclerosis or a similar disease and the SNOMED CT hierarchy allows such semantics to be understood algorithmically.
Why SNOMED CT will be used
SNOMED CT provided a comprehensive and exhaustive list of clinical terms that are understandable to clinicians and at any point, it is possible to limit user searches to a subset or tree of terms / synonyms appropriate for the data field in question.
As a standard terminology in Wales and England, when we generate clinical correspondence, these clinical terms can be included in the bundle to support interoperability with future systems that will support SNOMED CT.
