Define to which area this concept can be applied
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6 Comments
Francisco Jose Rodriguez Alcazar
Hi everyone.
Currently, we are identifying which SNOMED CT concepts are related to reports made by nurses.
As a whole, we have detected one that is:
en- Outpatient nursing report (record artifact) OR en-Outpatient nursing report(SCTID: 4181000179103)
Parents
SNOMED CT concept (SNOMED RT + CTV3)
record artifact (record artifact)
record organizer (record artifact)
record composition (record artifact)
report (record artifact)
nursing report (record artifact)
outpatient nursing report (record artifact)
The question is whether this concept refers to:
I am open to working on this concept "nursing report (record artifact)" to be able to analyze existing ones and suggest new concepts.
A cordial greeting
Gertrude Petersson
What is the purpose of this concepts? Is it a kind of 422735006 |Summary clinical document (record artifact)|/371535009 |Transfer summary report (record artifact)|?
Why is it important to highlight "goes to hospital care consultation" is it a refferal?
The same question about "goes to hemodialysis treatment" and "any type of cre that does not require hosptalization"
Best regards Gertrude Petersson
Zac Whitewood-Moores
The concept itself has no information other than it is an outpatient nursing report, therefore I would normally expect it to be a nursing report from hospital outpatients.
Cathy Richardson
Francisco Jose Rodriguez Alcazar Thank you for raising this question. The concept 4181000179103 |Outpatient nursing report (record artifact)| represents a type of clinical document, see Record Artifact from the current Editorial Guide. A noted by Zac Whitewood-Moores the only meaning that can be inferred is that it is an outpatient nursing report document.
Record artifact content is more often added at an extension level. Looking in the browser:https://browser.ihtsdotools.org/? a small amount of nursing Record artifact content has been added by the UK and one by the Netherlands.
Francisco Jose Rodriguez Alcazar
The objective of our work is to codify those nurse reports in hemodialysis care. We interpret that report to include any hospital treatment of a patient who is not physically admitted to an inpatient bed. Neither emergency reports. Thank you all for your responses.
Zac Whitewood-Moores
It largely depends on how nursing and multidisciplinary care is to be documented, 736375002 |Hemodialysis care plan (record artifact)| COULD be used if care is typically planned and evaluated, however if you wish to represent a report sent to primary care this may be less suitable. Many nations are now making full records available to other sectors of the healthcare system (and patients) and thus summary/discharge reports are becoming less critical. In addition a pre-coordinated representation for every service, health issue etc may be less scalable and probably undesirable too. Most services could use common structures in FHIR messages but this is why both international and national communities cannot consider terminology in isolation.