SNOMED CT Editorial Guide

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The following defining attributes correspond to the Procedure Attributes Summary table from the HRCM.

Self-grouped Attributes

The following attributes are self-grouped, meaning they are not grouped with any other attributes:

  • Priority
  • Has focus


Access

Access (attribute) describes the route used to access the site of a procedure. It distinguishes open, closed, and percutaneous procedures.

For example, 

Direct device

Direct device (attribute) represents the device on which the method directly acts.

For example, 

Direct morphology

Direct morphology (attribute) describes the morphologically abnormal structure that is the direct object of the Method action.

For example,

Direct substance

Direct substance (attribute) describes the Substance or Pharmaceutical/biologic product on which the procedure's method directly acts.

For example, 

    • 231274008 |Injection of steroid into joint (procedure)| has Direct substance (attribute) of Steroid (substance)

Figure 1: Stated view of 231274008 |Injection of steroid into joint (procedure)| with Direct substance (attribute) of Steroid (substance)

Pharmaceutical / biologic product

Although Pharmaceutical / biologic product (product) and its descendants are considered valid values for the Direct substance (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.

Has focus

Has focus (attribute) specifies the Clinical finding or Procedure which is the focus of a procedure.  This attribute is self-grouped.  

For example, 

Has intent

The Has intent attribute is used when a procedure may be performed for various reasons, described with subtypes of 363675004 |Intents (nature of procedure values) (qualifier value)|, such as diagnostic, palliative, preventive, therapeutic, etc. These intents are not used to define procedures with intents that are inherent to the procedure; such as biopsies that are by definition diagnostic, or fracture fixations which are always therapeutic. 

The Has intent attribute should be grouped with other attributes that represent the procedure with that intent.

For example, 

Indirect device

Indirect device (attribute) represents action on something that is located in or on a device, but is not directly on the device itself. This attribute is infrequently needed. When modeling, carefully consider its use.

For example, 

In this example, the vegetation is being excised. The mitral valve prosthesis device is where the vegetation is located, but the mitral valve prosthesis, itself, is not excised. Thus, the mitral valve prosthesis device is the Indirect device.

Indirect morphology

Indirect morphology (attribute) describes the morphology that is acted upon, but is not the direct object of the Method action. This means the procedure acts directly on something else, e.g. a device, substance, or anatomical structure.

For example, 

Method

Method (attribute) represents the action being performed to accomplish the procedure.

For example,

Procedures with a Method (attribute) can be described using an action verb that corresponds to the method. The direct object/s of the action verb should be represented using one or more of the four direct-object attributes, depending on whether the direct object on which the method acts is an:

  • Anatomical structure: Procedure site - Direct
  • Morphologic abnormality: Direct morphology
  • Device: Direct Device
  • Substance: Direct Substance

If the anatomical structure, device, or substance of the direct object is indeterminate, do not use the direct-object attributes.

When modeling procedures where the Method is Removal - action (qualifier value) or one of its subtypes, e.g. Excision, Surgical biopsy, etc., for removal of:

  • Structures, grafts, and tissue lesions (e.g. cysts, tumors, etc. are considered removal of the site), use Procedure site - Direct.
  • Devices, calculi, thrombi, foreign bodies, and other non-tissue entities from the structure, use Procedure site - Indirect.

For example, 

    • 43748006 |Removal of urinary bladder catheter (procedure)| has a Method (attribute) of Removal - action (qualifier value).  Because a device is being removed, use Procedure site - Indirect (attribute) with a value of Bladder and outflow structure (body structure)

Method (attribute) does not describe

  • surgical approach, e.g. translumbar
  • equipment, e.g. sutures
  • physical force, e.g. laser energy

Method attribute grouping

Attributes should be grouped with the Method (attribute) to which they apply. In the absence of a Method (attribute), related attributes should be grouped together.

Exception,

    • Recipient category (attribute)
      • A single procedure concept should not be precoordinated when more than one Recipient Category is involved. Such complex statements should have two or more procedure concepts that are placed into an appropriately structured electronic health application.
      • See separate attribute entry for Recipient category below.

No relationship group can contain more than one Method (attribute).  If a procedure has more than one method, each Method (attribute) serves as the anchor of a separate relationship group that will contain any defining relationships that represent a direct object (and, where relevant, indirect object) of the Method's action.  This is true even if the different Methods each act on the same direct object.  Each relationship group can be thought of as representing a component of the procedure that involves a particular action.   

Priority

Priority (attribute) is used when a procedure concept specifies a priority.  This attribute is self-grouped.  

For example, 

260870009 | Priority (attribute)|  is most often used to differentiate elective and emergency subtypes of a procedure that can be performed on either basis. With the exception of Cardiopulmonary resuscitation (procedure), this attribute is normally used only to define concepts whose FSNs specify a priority, not for modeling procedures that imply an emergency priority, such as |Heimlich maneuver (procedure)| or those that are inherently elective, such as |Augmentation mammoplasty (procedure)|.

Procedure device

Procedure device (attribute) is used to model devices associated with a procedure. This attribute is used to define high-level, general concepts that aggregate procedures according to the device involved.

Procedure device subsumes the more specific attributes, Direct Device, Indirect Device, Using Device, and Using Access Device. The more specific attributes should be used instead of Procedure Device, if possible.

For example, 

Procedure device

The attribute values in the Procedure Device hierarchy include Device (physical object) and its descendants.

There are a limited number of drug delivery devices in SNOMED CT. These concepts descend from Drug-device combination product (product) which is a descendant of both Device (physical object) and Pharmaceutical / biologic product (product). Although they carry the hierarchy tag of (product), they are acceptable values for attributes in the Procedure Device attribute hierarchy.

Procedure morphology

Procedure morphology (attribute) is used to specify the morphology, or abnormal structure, involved in a procedure. It is used when defining general concepts that subsume direct and indirect morphology. It subsumes the more specific attributes, Direct and Indirect Morphology. These should be used, if possible.

Morphologically abnormal structures

Hematoma, calculus, foreign body, blood clot, embolus, and some other morphologies are not strictly body structures. But, they are included in the body structure hierarchy under morphologically abnormal structure and are valid values for the Procedure Morphology attributes.

Procedure site

Procedure site (attribute) describes the body site acted on or affected by a procedure.  The Procedure site (attribute) is

363704007 | Procedure site (attribute)| subsumes the more specific attributes, 405813007 | Procedure site - Direct (attribute)| , which is the site directly acted upon, and 405814001 | Procedure site - Indirect (attribute)| , which is the site indirectly acted upon.  The more specific attributes should be used if possible (see separate entries for Procedure site - Direct and Procedure site - Indirect).

For example, 

When modeling procedures where the Method is Removal - action (qualifier value) or one of its subtypes, e.g. Excision, Surgical biopsy, etc., for removal of:

  • Structures, grafts, and tissue lesions (e.g. cysts, neoplasms, abscesses, wounds, warts, aneurysms, herniations, oral clefts, etc.) are considered removal of the site, use Procedure site - Direct.
  • Devices, calculi, thrombi, foreign bodies, and other non-tissue entities from the structure, use Procedure site - Indirect.

Procedure site

Procedures are not necessarily categorized by site.

Use of Structure of <anatomical structure> vs. Entire <anatomical structure> as value of the Procedure site attributes

Structure of <anatomical structure> rather than Entire <anatomical structure> should be used as the value for procedure site attributes, except where the procedure FSN explicitly specified that the entire structure is the object of the procedure.

For example,

Procedure site - direct

Procedure site - Direct (attribute) is used when the action of the procedure is directly aimed at anatomical or acquired body structure or site, rather than something else located there (e.g. a device), i.e. when the 260686004 | Method (attribute)| is 129303008 | Removal - action (qualifier value)| or one of its subtypes (Excision, Surgical biopsy, or etc.). 

For example,

Tissue lesions (cysts, neoplasms, abscesses, wounds, warts, aneurysms, herniations, oral clefts, etc.) are considered part of the procedure site and should also use 405813007 | Procedure site - Direct (attribute)| .

For example,

  • Repair of rectocele (procedure) has a Procedure site - Direct (attribute) of Rectum structure and a Direct morphology (attribute) of Herniated structure
  • Closure of skin wound (procedure) has a Procedure site - Direct (attribute) of Skin structure and a Direct morphology (attribute) of Wound
  • Fixation of fracture (procedure) has a Procedure site - Direct (attribute) of Bone structure and a Direct morphology (attribute) of Fracture


Procedure site - indirect

Procedure site - Indirect (attribute) specifies the anatomical location but is not the direct focus of the procedure.  The direct object of the action may be a device, a substance, or a morphologic abnormality that is not a part of the tissue structure of the anatomical site in which it is located, such as a calculus, thrombus, or foreign body. Thus, 405814001 | Procedure site - Indirect (attribute)|  is typically found in a relationship group with a second, "direct" attribute-value relationship, such as a Direct morphology, Direct substance, or Direct device.

For example, 

Figure 2: Stated view of 405433000 |Removal of catheter from brachial vein (procedure)|


Figure 2: Stated view of 371005009 |Removal of calculus of urinary bladder (procedure)|


Recipient category

Recipient category (attribute) specifies the type of individual or group upon which the action of the procedure is performed.

For example, 

This can be used in blood banking procedures to differentiate the donor vs the recipient of blood products.

Recipient category

It is not used for a procedure where the subject of the procedure is someone other than the subject of record.

Revision status

Revision status (attribute) refers to another procedure performed on the same site for the same condition. A procedure without a revision status is considered to be performed for the first time. A revision procedure can be modeled with a Revision status (attribute) of Revision - value (qualifier value).

For example,

Using access device

Using access device (attribute) specifies the instrument or equipment used to access the site of a procedure.

For example, 

Using device

Using device (attribute) refers to the instrument or equipment utilized to execute an action. It is used when the device is actually used to carry out the action, that is the focus of the procedure. If the device is simply the means to access the site of the procedure, then Using access device is the appropriate attribute.

For example, 

Using energy

Using energy (attribute) refers to the energy used to execute an action. 

For example, 

Using substance

Using substance (attribute) describes the Substance used to execute the action of a procedure. It is not the substance on which the procedure's method directly acts, the Direct substance.

For example, 

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