An example of a multi-professional process-oriented structured documentation bound to SNOMED CT

Carina Zetterberg, Karin Ahlzén, Erika Ericsson, Bengt Kron
Studies in Health Technology and Informatics 2012, 180: 1215-7
Structured code-based documentation, i.e. templates which restrain the user with predetermined terms/phrases bound to terminologies, offers opportunities for advanced types of retrieval and guides the user in multiple ways; to act in accordance with evidence, for decision support and to achieve adequate documentation for the condition in question. This type of documentation is especially appropriate in health care processes which are nearly the same every time. A template for documentation of the family planning process (abortion) was elaborated at a Swedish hospital. It uses both structured elements and free-text and covers all information needed in the process. The predetermined terms and phrases were bound to SNOMED CT concepts. After the template has been completed, it forms the basis for a customary free-text note in the record. The structured information is also stored in its original form and can be used for different kinds of advanced data retrieval. The documentation is completed during the visit and there is no need for additional secretarial work. The implementation has reduced the total time used for documentation, reporting and follow up and shows that process-oriented structured documentation bound to SNOMED CT improves the documentation, supports advanced retrieval of data and reduces resource utilization.

Full Text Links

Find Full Text Links for this Article


You are not logged in. Sign Up or Log In to join the discussion.

Related Papers

Remove bar
Read by QxMD icon Read

Save your favorite articles in one place with a free QxMD account.


Search Tips

Use Boolean operators: AND/OR

diabetic AND foot
diabetes OR diabetic

Exclude a word using the 'minus' sign

Virchow -triad

Use Parentheses

water AND (cup OR glass)

Add an asterisk (*) at end of a word to include word stems

Neuro* will search for Neurology, Neuroscientist, Neurological, and so on

Use quotes to search for an exact phrase

"primary prevention of cancer"
(heart or cardiac or cardio*) AND arrest -"American Heart Association"