SNOMED and Its Use in Nursing Care

SNOMED and Its Use in Nursing What is SNOMED?

SNOMED, which stands for Systematized Nomenclature of Medicine – Clinical Terms, is a comprehensive, systematically organized, and computer-processable collection of medical terms. It provides a set of codes, terms, synonyms, and definitions used in clinical documentation and reporting within the healthcare system. SNOMED is used by healthcare professionals globally to ensure consistency and accuracy in medical records, making it an essential tool in clinical practice, research, and health informatics.

SNOMED serves as a universal language that enables healthcare providers to exchange and interpret clinical health information across various systems. It helps in improving patient care by ensuring accurate communication between different healthcare providers, supporting clinical decision-making, and enhancing the quality of healthcare delivery. SNOMED’s comprehensive structure allows for a wide range of medical terms, from specific diseases to procedures and clinical findings, making it a critical tool for documentation in electronic health records (EHRs).

11 Modules of SNOMED International

SNOMED International is organized into 11 modules or axes, which represent different aspects of clinical terminology. These modules are:

1. Topography: Refers to the anatomical locations or body sites.
2. Morphology: Describes the form and structure of tissues or organs, often used in pathology.
3. Living Organisms: Includes all biological entities, such as bacteria, viruses, and other microorganisms.
4. Chemicals, Drugs, and Biological Products: Contains terms for various medications, chemical agents, and biologics used in healthcare.
5. Functions: Represents physiological and psychological functions, as well as abnormal functions.
6. Occupation: Refers to the roles or jobs of patients and healthcare providers.
7. Diagnosis: Provides standardized terminology for diagnoses, including diseases and conditions.
8. Procedures: Includes all medical, surgical, and nursing procedures.
9. Physical Agents, Forces, and Attributes: Contains terms related to physical factors that affect health, such as radiation or pressure.
10. Social Context: Describes social and environmental factors that impact health, including lifestyle and socioeconomic status.
11. General: Covers a wide range of additional terms and modifiers that do not fit neatly into the other modules (Coté, Rothwell, Palotay, & Beckett, 1993).

These modules work together to provide a structured and comprehensive nomenclature that supports detailed clinical documentation.

Role of NANDA

The North American Nursing Diagnosis Association (NANDA) plays a significant role in SNOMED’s functional axis. NANDA’s standardized nursing diagnoses are incorporated into the functional module of SNOMED. Additionally, a limited number of nursing procedures are included in the procedure module.

Unlike other taxonomic vocabulary systems, such as the International Classification of Diseases (ICD) or Current Procedural Terminology (CPT) codes, which focus on disjunctive classification, SNOMED terms are designed to be combined to represent complex clinical concepts for computer-based systems. For example, the term “pain” from the function axis can be combined with a severity modifier from the general axis to represent “severe pain” or with an anatomical term from the topography axis to represent “back pain.”

This multiaxial approach is similar to the proposed architecture of the International Classification of Nursing Practice (ICNP). Various studies have demonstrated the utility of SNOMED for physician documentation, and some have explored its potential for nursing documentation as well.

Integration of SNOMED with Nursing Documentation

Nurses often use both NANDA diagnoses and other clinical terms (e.g., symptoms, signs, medical diagnoses) to describe patient problems. Research has shown that many terms used by nurses in clinical documentation can be found in SNOMED, even if they are not part of the NANDA diagnoses. For example, Lange (1996) found that SNOMED terms were useful for representing the terminology used by nurses in inter-shift reports.

Moreover, J. Campbell et al. (1997) compared SNOMED International with the Read Codes and the Unified Medical Language System (UMLS) across several attributes, including completeness, clinical taxonomy, administrative mapping, term definitions, and clarity. Their analysis of 1,929 records, which included 390 nursing documents, showed that SNOMED was superior in several areas relevant to nursing.

UMLS Four Categories and SNOMED

The Unified Medical Language System (UMLS) is another comprehensive system designed to facilitate the integration of biomedical information across different formats and sources. It incorporates four main categories of clinical information:

1. Findings: Observations made by healthcare professionals.
2. Diagnoses: Clinical diagnoses and related terms.
3. Interventions: Medical and nursing interventions.
4. Plans of Care: Planned actions to manage patient care.

SNOMED was found to be superior to Read Codes and UMLS on the four categories of information (findings, diagnoses, interventions, and plans of care) that comprised more than 97% of the nursing text sources. It was judged to be more complete, taxonomically accurate, and compositional in nature than the other systems. However, SNOMED received lower ratings for administrative mappings compared to Read Codes and UMLS.

If the analyses related to nursing interventions and plans of care had been reported separately from other healthcare interventions and plans of care, the findings might have differed concerning the attribute of completeness. This is because the UMLS includes nursing intervention schema from the Omaha System, the Georgetown Home Health Care Classification, and the Nursing Interventions Classification, which are not included in SNOMED.

Enhancing SNOMED for Nursing

While SNOMED has demonstrated some utility for nursing, further work is needed to increase its usefulness in the field. Three areas need specific attention:

1. Addition of Nursing Terms: Additional terms for nursing interventions need to be incorporated into SNOMED to cover the full range of nursing activities.
2. Development of Grammar Rules: Rules or grammars for combining terms need to be developed using formal methods such as conceptual graphs to accurately represent complex nursing concepts.
3. Creation of Data Models: Data models that describe the unique attributes of nursing data must be developed to enhance the representation of nursing concepts in computer-based systems.

Conclusion

SNOMED International plays a crucial role in standardizing clinical documentation across healthcare systems worldwide. While it has proven effective for physician documentation, its integration into nursing practice requires further development. By adding more nursing-specific terms, creating grammar rules for combining terms, and developing tailored data models, SNOMED can better support nursing documentation, leading to improved patient care and better health outcomes. Continued research and refinement will ensure that SNOMED remains a valuable tool in the evolving landscape of healthcare.