JOURNAL ARTICLE

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
22874405
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.

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