SNOMED CT Editorial Guide

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Tip
titleSelf-grouped Attributes

Generally, the attributes attributes associated with, before, during, after, due to, clinical course, or temporally related to are self-grouped, meaning they must not be placed in a relationship group with other attributes; each attribute must be the only attribute in a relationship group.  Any rare exceptions will be documented within the individual attribute section below.

The Human Readable Concept Model (HRCM) grouped column (see the Clinical Finding Attributes Summary table on the previous page) correctly indicates that these attributes are put into a relationship group during classification because they are self-grouped.

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    • Concept
      t4989003 |Electrical burn of skin (disorder)|
       has the 
      Concept
      t246075003 |Causative agent (attribute)|
             of 
      Concept
      t18213006 |Electricity (physical force)|

Warning

Although Pharmaceutical / biologic product (product) and its descendants are considered valid values for Causative agent (attribute) by the MRCM, they are not currently used as values for this attribute in the International Release. The only exception is 787859002 |Vaccine product (medicinal product)| and its descendants, which can be used as valid values for this attribute.

The following guidelines should be considered where the causative agent is a substance:

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Concepts representing a clinical finding caused by a substance role grouper modification (e.g., 372688009 82485006 |Antineoplastic agent Pentamethonium bromide (substance)|) currently follow the same guidelines noted above. However, role groupers will be transitioned from the Substance hierarchy to the 763158003 |Medicinal product (product)| hierarchy in a future release.

For example,

  • 295597003 |Antineoplastic overdose (disorder)|

Concepts representing a clinical finding caused by a substance modification (e.g., 82485006 |Pentamethonium bromide (substance)|) are generally not allowed. Exceptions may be included if the condition caused by the substance modification is significantly different from the one caused by the base substance. Exceptions may include are generally not allowed. Exceptions may be included if the condition caused by the substance modification is significantly different from the one caused by the base substance. Exceptions may include Liposome or lipid complex substances, Pegylated substances, or salt forms:

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Note
titleThe word acute

The word acute has more than one meaning, and the meanings are often overlapping or unclear. It may imply rapid onset, short duration, or high severity; in some circumstances it might be used to mean all of these. For morphological concepts, acute may also imply the kind of morphology associated with the speed of onset.

For example,

    • Concept
      t4532008 |Acute inflammation (morphologic abnormality)|
      does not necessarily have a clinical course of sudden onset and/or short duration, but rather implies polymorphonuclear infiltration (
      Concept
      t84499006 |Chronic inflammation (morphologic abnormality)|
       implies mononuclear cell infiltration, not necessarily a chronic course, although inflammation with a chronic course is highly correlated with a lymphocytic infiltration)

2704003 |Acute disease (disorder)| is modeled with a Clinical course (attribute) of Sudden onset AND/OR short duration (qualifier value).  For clinical conditions that necessitate further specificity, the more appropriate subtypes are available.  Acute onset and sudden onset are synonymous; clinical conditions specifying acute onset should be modeled with a Clinical course (attribute) of Sudden onset (qualifier value)course (attribute) of Sudden onset (qualifier value).

Acute-on-chronic (qualifier value) is an acute (sudden onset) event superimposed on a pre-existing chronic condition. This be either a sudden worsening of a chronic condition itself (an exacerbation) or the development of a new, separate acute illness on top of a chronic disease.

Due to

This attribute is used to identify a clinical finding/disorder, event, or procedure concept as the direct cause of another Clinical finding or Disorder concept.  If the clinical finding merely predisposes to another disorder, rather than causing it directly, the more general

Concept
tAssociated with (attribute)
 is used instead.  

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This attribute specifies the person or other entity from which the clinical finding information was obtained. It is not about the particular individual but about the category or type of informer. It is used to differentiate patient-reported symptoms from provider-determined signs. This attribute is frequently used in conjunction with 

Concept
t418775008 |Finding method (attribute)|
. 

Finding method

This attribute specifies the means by which a clinical finding was determined. It includes findings that were determined by examination of the patient. Finding method is frequently used with Finding informer. 

For example,

    • Concept
      t713071004 |Alcohol misuser in household (finding)|
       has the 
      Concept
      t418775008 |Finding method (attribute)|
       of
      Concept
      t84100007 |History taking (procedure)|

...

This attribute is used to subclass a Clinical finding concept according to its severity. However, this use is relative, i.e. it is incorrect to assume that the disease intensity or hazard is the same for all clinical findings to which this attribute is applied. 

The severity attribute 246112005 |Severity (attribute)| may be applied to subtypes of Clinical finding (excluding << Symptom severity (finding)) to represent the severity of a finding or disease.  

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Tip
titleModeling

Generally, 246112005 |Severity (attribute)|  is is not used to model concepts precoordinated in the International precoordinated in the International Release,  but but there are some exceptions. 

A valid exception requires an internationally accepted definition that can be consistently applied and used reliably for international comparison.  Even though a reference may be internationally sourced, its use may not always be uniformly applied by multiple countries. Classifications of severity that represent variation in clinical presentations and enact limitations with age ranges, sex, or pregnancy status, do not apply universally to all patients of all ages, prove problematic, and may not be generally useful. 

The requestor is responsible for obtaining permission for use in SNOMED CT if required by the international body.  

As an alternative to precoordination in the international release, this attribute can be used as a qualifier in postcoordination.  However, beware that postcoordination of severity results in the same irreproducibility issues as pre-coordination. 

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726633004 |Temporally related to (attribute)| applies to perioperative complications and clinical findings where there is no causal relationship , but a time-relative association exists.

The This attribute's subhierarchy specifies the associated time period (i.e. before, during, after) between two procedures, two clinical findings, or a procedure and a clinical finding, e.g., |Pediatric inflammatory multisystem syndrome temporally associated with COVID-19|; or between a clinical finding and a procedure, e.g., perioperative complications temporally related to a surgical procedure (i.e. preoperative, intraoperative, and postoperative); Multisystem inflammatory syndrome in children temporally associated with SARS-CoV-2.  

This attribute is self-grouped.