A Clinical finding/Disorder concept's fully specified name (FSN) must be specific, though the preferred term (PT) can be a more clinician-friendly, word-order variant.
The FSN must conform to a specific pattern of "Disease of x" where a specific body structure is involved. For the preferred term, end users can choose the desired description that conforms to common clinical usage.
For example,
FSN: Disease of kidney (disorder)
PT: Can be either 'Kidney disease' or 'Renal disease'
The use of -opathy is to be used in the preferred term, because the FSN is to be specific and explicit, and there are often various interpretations of -opathy. A term containing the suffix -opathy can only be used in the FSN if a definition is applied via the DEF description.
For example,
FSN: Disorder of macula of retina (disorder)
PT: Can be either 'Disorder of macula of retina' or 'Maculopathy'
The morphologic abnormality is named before naming the anatomical site.
For example,
- In 399525009 | Inflammation of ampulla of Vater (disorder)| , Inflammation is the morphologic abnormality and Ampulla of Vater is the finding site.
While the general naming convention for findings and disorders is <Morphology> of <x body structure>, there are some exceptions:
- Disorders with a well recognized name that represents the morphology; e.g. pneumonia is the well established clinical name for inflammation and infection of the lung
- Disorders where the meaning is not equivalent to <morphology> of <x> site convention; e.g. inflammatory bowel disease has a more specific meaning than inflammation of bowel
- Disorders which are not described by an anatomical site; e.g. metabolic disease, hereditary disease, bacterial disease
Please see documented naming patterns:
- Completed or in review - Precoordination Naming Pattern Project
- Proposed for future review - Unreviewed Naming Patterns by Hierarchy
Descriptions that include body structures
Descriptions for Clinical findings and disorders should follow the naming guidelines for Body structures if they are to be used within the Clinical finding/disorder concept. Concepts describing limbs are abundant, and the use of limb in the FSN and the synonyms of upper/lower extremity, arm/leg should be followed.
For example,
249945007 |Monoparesis of lower limb (disorder)|
Because the finding site is 61685007 |Lower limb structure (body structure)|, which follows the anatomical guidelines, the disorder concept reflects lower limb in the FSN, while using synonyms of Monoparesis of leg and Monoparesis of lower extremity.
Disorder
In the disorder hierarchy, the following naming conventions apply:
- The word disorder should be singular, so correct convention is Disorder of nose, not Disorders of nose.
Exceptions
Plurals may be used:
- As synonyms for grouper concepts, e.g. disorders or diseases
- In bilateral concepts, e.g. Disorder of bilateral eyes, Disorder of both eyes (see also Lateralized Disorder Naming Conventions)
- When the concept is a general grouping of disorders of a body system, body site, or other broad category, the word disorder is preferred over the word disease for the FSN, e.g. Disorder of reproductive system, not Disease of reproductive system. This does not apply at the leaf level.
For example,
For naming conventions concerning surgical complications, sequelae, and late effects, see this section at Complication and Sequela Modeling.
Disorder X without Disorder Y
The vast majority of existing X without Y concepts originated from ICD-9 with the specific meaning of "X disorder without mention of Y disorder". As the phraseology indicates a lack of data about disorder Y as opposed to a specific exclusion, this type of concept has not been included in ICD-10, nor proposed for ICD-11, except in the case of "Traumatic brain injury without open intracranial wound".
Addition of new X without Y concepts may only be made under the following conditions:
- The request for new content must be accompanied by a rationale as to the difference between "X disorder without Y disorder" and "X disorder"
- Approval of addition by the Chief Terminologist
For the most part, existing X without Y concepts will be inactivated as AMBIGUOUS with a historical MAY BE relationship to "X disorder". Exceptions to inactivation will be made on a case-by-case basis.
Requires [procedure/drug] (finding)
SNOMED international is no longer accepting new requests for concepts of the type – Requires [procedure/drug] (finding). These are administrative statuses rather than clinical findings, and this status should be represented outside of the terminology in the information model. The only exceptions relate to legacy content, and requests for subtypes of 723620004 |Requires vaccination (finding)| will continue to be accepted.
Region
If the
363698007
|
Finding site (attribute)|
value of a concept is a body structure with "region" in its FSN, then the description of the finding site within the clinical finding concept's FSN should also include "region".
For example, 274205003 | Burn of eye region (disorder)| has a finding site of 371398005 | Eye region structure (body structure)| .
- FSN: Burn of eye region (disorder)
- PT: Burn of eye region
Figure 1: Stated view of |Burn of eye region (disorder)|
Allergy to substances, multiple substances
Previously, allergies caused by multiple substances were modeled by multiple causative agents suggesting that the allergy is caused by all those substances. However, when multiple substances are noted in the FSN, the intended clinical meaning is that a patient might be affected by one or more of these substances (or products containing them). To convey this meaning, these types of concepts should be modeled GCIs to represent the disjunctive meaning. e.g. 870731003 |Allergy to carbidopa and/or levodopa (finding)|
Information
The modeling approach for multiple-ingredient concepts is a temporary solution. It incorrectly asserts an allergy/adverse reaction to each, rather than to one, agent. The use of concepts from the Pharmaceutical/biologic product hierarchy is being considered as a final solution, but further work is required to determine if this would be a viable solution.
Allergic and nonallergic hypersensitivity (pseudoallergic) dispositions
Allergic and nonallergic hypersensitivity (pseudoallergic) dispositions are the propensity to develop adverse allergic or nonallergic hypersensitivity (pseudoallergic) disorders. A description for any concept that names a substance or an organism should be consistent with the corresponding hierarchy description rules.
Drug allergies
Allergic and nonallergic hypersensitivity (pseudoallergic) concepts include drug allergies.
Patterns:
FSN: Allergy to X (finding)
PT: Allergy to X
For example,
- FSN: Allergy to abacavir (finding)
- PT: Allergy to abacavir
- FSN: Allergy to Artemisia vulgaris pollen (finding)
- PT: Allergy to mugwort pollen
FSN: Allergy to X and Y (finding)
PT: Allergy to X and Y
- X and Y in alphabetical order for concepts representing multiple substances
Allergic and nonallergic hypersensitivity (pseudoallergic) disorders
These disorders represent manifestations of pathologic processes that may result in abnormal structures (e.g., allergic rhinitis).
| Disorder | Patterns and examples |
|---|---|
FSN | Patterns:
For example,
|
PT | Patterns:
For example,
|
Allergic and nonallergic hypersensitivity (pseudoallergic) reactions
These disorders represent pathological processes that are defined as adverse reactions and allergic conditions with a pathological process of allergic or nonallergic hypersensitivity (pseudoallergic) process.
| Reaction | Patterns and examples |
|---|---|
| FSN | Patterns:
For example,
|
| PT | Patterns:
For example,
|
Contact hypersensitivity
Contact hypersensitivity represents a response elicited by contact of the skin or mucous membranes with a substance. The response may be immune mediated (allergic) or nonimmune (irritant) using the pathological process contact hypersensitivity process (qualifier value).
For example,
- Contact dermatitis (disorder)
- Irritant contact dermatitis (disorder)
Intolerance to substances
An intolerance is the propensity to develop an adverse reaction to a substance. The nature of the adverse reaction can represent a variety of pathological processes but specifically excludes hypersensitivity (allergic and nonallergic hypersensitivity (pseudoallergic) reactions.
Due to the difficulty in precisely defining an intolerance pathological process, it is problematic to apply the model for hypersensitivity dispositions to defining intolerance to substance. For this reason, as well as the difficulty in associating a material agent with a disposition, substances are related to the intolerance disposition with the associated with attribute.
| Intolerance | Patterns and examples |
|---|---|
| FSN | Pattern:
Example,
|
| PT | Pattern:
Example,
|
Inadequate and excessive intake of energy and nutrients
Identification of findings of inadequate or excessive intake of nutrients inconsistent with nutrient requirements and established reference standards includes nutrients with a variety of forms where applicable.
For example, 870465001 | Excessive intake of vitamin A and vitamin A derivative (finding)|
FSN: Excessive intake of vitamin A and vitamin A derivative (finding)
PT: Excessive intake of vitamin A and vitamin A derivative
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