SNOMED CT Editorial Guide

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General rules

The naming pattern for procedures is highly dependent on the attributes used to describe the procedure. However, some general rules apply.

The FSN for a procedure should name the action (the method) of the procedure first, and then the object that the action directly acts upon. 

For example,

Include the approach where more than one option exists. See the various approaches as subtypes of 103379005 |Procedural approach (qualifier value)|.   

For example,

  • 386792000 Transurethral resection of neoplasm of bladder (procedure) vs 287726000 Open resection of neoplasm of bladder (procedure)

Because a resection of a neoplasm of the bladder can be performed by transurethral and open approaches, concepts are separately identified with each approach.

Use via for route or approach and using for device. 

For example,

  • Administration of sedative via nasal route (procedure)
  • Internal fixation using screw (procedure)

One description, either preferred term or synonym, should match the FSN without the semantic tag.  Synonyms and/or preferred terms using the common clinical names of procedures are acceptable. 

A common naming pattern for concepts in the procedure hierarchy is:

FSN: <Method (Action)> of <Anatomical or acquired body structure> (procedure)

PT:    <Method (Action)> of <Anatomical or acquired body structure>

SYN: [plasty/stomy/ectomy/otomy] 

For example,


Please see potential naming patterns:


Further refinements can be affected by the various attributes and their values as described in the sections below.

Anatomical site

An anatomical site is the direct object of the action. The name of the site should follow the name of the action.

For example,

The action is repair and the site is pulmonary artery.  The action is listed first in the description, followed by the site.

Procedure descriptions should follow the naming guidelines for the body structure hierarchy.  Concepts describing limbs are frequently found in SNOMED CT, and the use of upper/lower limb in the FSN with synonyms of upper/lower extremity, arm/leg should be followed.

For example,

The description of upper limb is used in the FSN while the synonyms refer to arm and upper extremity. 

Device

A device is the direct object of the action. The word(s) naming the device should follow the word(s) naming the action.  If there is a site that is not the direct object of the action, the word(s) naming it should come after the word(s) naming the device.

For example,

Substance

A substance is the direct object of the action. The word(s) that name the substance should follow the words that name the action. If there is a site that is not the direct object of the action, the word(s) naming it should follow the word(s) naming the substance.

For example,

Morphologic abnormality

A morphologic abnormality is the direct object of the action. The morphology term should follow the action term. If there is a site, it should follow the morphology term.

For example,

Past tense verbs and sentence types

A procedure concept should be a noun phrase that names the procedure. It should not contain information that it was done, or is to be ordered, carried out, or planned.

  • Past tense verbal phrases should not be used to name procedures, since past tense invokes a temporal context, i.e. the procedure was done in the past.  Any existing concepts with past tense verbs should be moved to the Situation with explicit context hierarchy.
  • Sentence function types, i.e. imperative, declarative, interrogative, or exclamatory, are disallowed in procedure concepts. 

Acceptable example,

Unacceptable example, 

    • Hand tendon ganglion excised indicates the procedure was done, as a past tense declarative statement. This should be in the Situation with explicit context hierarchy, not the Procedure hierarchy.

Complexity

Complexity can mean either the amount of effort required, or it can be based on realm-specific definitions (e.g. simple arthrodesis, simple repair, complex repair, etc.).  Procedure concepts with modifiers representing complexity are not allowed in the International Release.

Exception

Procedures that use the terms simple or complex are allowed if defined with reproducible meanings, based on what is done to or for the patient, rather than how much effort is expended.

For example,

    • 172043006 | Simple mastectomy (procedure)|   The concept is reproducibly defined as the removal of all breast tissue without removal of axillary contents. This is differentiated from modified radical, radical, skin-sparing, and subcutaneous variants of mastectomy.

Procedures by count

Counts of the number of procedures

Many procedure classifications focus on resources required to complete; this may be for reimbursement or tracking purposes (e.g. placement of one stent versus placement of two stents).  This information should be part of patient documentation and is not allowed in the International Release.

Order of procedures

The order of procedures, e.g. primary, first, second, etc. should be excluded.





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