Concepts in SNOMED CT carry a "soft-default" context, which means that, unless stated otherwise within the Description or the definition of the Concept, the term should be interpreted as follows:
For a clinical finding that:
- The finding has actually occurred (vs. being absent or not found).
- It is occurring to the subject of the record (the patient).
- It is occurring currently or at a stated past time.
For a procedure that:
- The procedure was completed.
- It was performed on the subject of the record (the patient).
- It was done in the present time or at a stated past time.
The only exceptions are Concepts whose Description actually contains a specific context (e.g. father smokes), and these are all grouped in a special hierarchy (situation with explicit context).
When recording in the patient record, post-coordinated expressions or free text should only be used to add additional detail to the coded item. They should never negate or modify the meaning of the coded item as this would fundamentally changes its meaning.
For example, free text phrases such as 'family history of', 'absent', 'not found' should not be applied to SNOMED CT coded data.
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