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Status:
Implemented
Category:
Clinical documentation
Description
Clinical documentation software for capturing synoptic, coded clinical encounter data including patient medical history, cancer treatment history, ambulatory visits, medication reconciliation, discharge summaries, pharmacy issues and interventions.
Scope
N/A
How SNOMED CT will be used
SNOMED CT terms are used where possible to encode clinical encounter data. Subsets or reference sets of SNOMED CT terms are conditionally loaded according to the medical or disease specialty of the clinical user. The complete set of SNOMED CT terms is searched for items not contained in a reference set in order to maximize the encoding of clinical encounter data for less frequent events.
Why SNOMED CT will be used
To adopt an international standard; to adopt a terminology standard that is maintained and validated by an external international standards body; relationship model of SNOMED CT enables the creation of more intelligent clinical software; future interoperability and cross-maps for ICD-10-CA codes.
