This section identifies the terminology services required to support practical entry of EHR data containing SNOMED CT concepts and expressions. It assumes that templates with appropriate terminology bindings have been created and applied using data entry design techniques identified in 3.2.2 EHR Data Entry Design.
Table 3.2.3-1 shows a summary of the terminology services required to support the most common types of EHR Data Entry. These service requirements are also sufficient to entry of postcoordinated expressions provided that these expressions are created using a specific predefined template.
Table 3.2.3-1: Terminology Services Required for EHR Data Entry
| Practical Requirement | Status 1 | Required Terminology Services2 | Additional Terminology Service Dependencies3 |
| Select the SNOMED CT edition and version to be used for data entry. | REQUIRED | 3.1.1 Select Edition and Version | N/A |
| Enable a concept, and where appropriate an associated term, to be recorded in response to the selection of a particular user interface option. | REQUIRED | 4.2 Get a Concept, Description or Relationship
| N/A |
| Display appropriate terms in search results, user interface lists, checkboxes, radio buttons and any other user interface controls in which options are represented by concept identifiers. | REQUIRED | N/A | |
Enable term searches to be constrained by value set bindings specified for each data entry field. | REQUIRED | 4.8 Find Concepts | One or more of the following services may be required depending on the range of search constraint types supported 3.1.5 Get and Test Concept Subtypes and Supertypes
3.1.6 Test Reference Set Membership |
Enable term searches to be constrained by simple constraints specified by the user to narrow a search. | OPTIONAL | ||
| Enable searches for attribute refinements to be automatically constrained by the appropriate concept model range constraint. | OPTIONAL | 3.1.4 Get Definition of a Concept
| |
| Enable the display of the definition of a selected concept. | OPTIONAL | 4.4 Get Definition of a Concept | N/A |
| Enable the display of supertype parents and subtype children of selected items in a search result list. | OPTIONAL | 4.5 Get and Test Concept Subtypes and Supertypes
| N/A |
Enable the validation of a generated postcoordinated expression prior to adding it to a record entry. | OPTIONAL | 4.14 Validate Concept Definitions and Expressions
| N/A |
Data entry methods that generate adhoc postcoordinated expressions, without a specific predefined template, have additional requirements for access to the concept definitions and the concept model rules. For example, a user interface control could be designed to respond to the selection of a SNOMED CT concept by displaying options that allow a user to select one or more attributes applicable to the concept's domain. The user could then be prompted for values for each selected attribute allowing them to refine the meaning of the selected concept. Another technique involves natural language processing (NLP) identifying the primary focus concept and any relevant refinements stated in a passage of text4. Additional terminology service requirements for these techniques are summarized in Table 3.2.3-2.
Table 3.2.3-2: Additional Terminology Services Required for Adhoc Postcoordinated Data Entry
| Practical Requirement | Status (for adhoc postcoordination) | Required Terminology Services | Additional Terminology Service Dependencies |
| Enable access to the definition of a selected concept. | REQUIRED | 4.4 Get Definition of a Concept | N/A |
| Enable the identification of attributes that can be applied to a selected concept. | REQUIRED |
| N/A |
| Enable the identification of the range of values that can be applied to a selected attribute. | REQUIRED | 4.4 Get Definition of a Concept
| N/A |
Enable the validation of a generated postcoordinated expression prior to adding it to a record entry. | OPTIONAL | 4.14 Validate Concept Definitions and Expressions
| N/A |
Footnotes
Applications designed to address this use case must support the practical requirements marked as Required. Support for the practical requirements marked as Optional is recommended as these provide enhanced functionality that may be required by some users.
In most cases, a reference to a subsection of 4 Terminology Service Types, implies a requirement for all services marked as Required in that subsection. However, where a reference is followed by a bulleted list, that list specifies the specific terminology services required. Some of the specific services listed as required for an Optional practical requirement may be marked as Recommended in the referenced subsection.
The Additional Terminology Service Dependencies column contains references to services on which a Required Terminology Service depends. This column does not restate dependencies on services listed as required service or additional dependencies for essential requirements listed in earlier rows. A full list of the dependencies of each terminology service is provided in the relevant subsection of 4 Terminology Service Types.
Natural language processing services are distinct from terminology services are not documented in this guide.
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