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Abstrakt

Generally clinical documentation should be precise and unambiguous, but often this is not the case. This is the case for clinical subjective evaluations like “decrease in appetite”. This paper examines if the precision of the evaluation can be improved by mapping to SNOMED CT. Two examples of subjective clinical evaluations from real clinical documentation are mapped to SNOMED CT using three different modelling approaches in order fit pre-defined levels of precision. The findings suggest that mapping to SNOMED CT alone cannot improve the precision, but by mapping the context of the subjective evaluation or the underlying objective observations, the precision might be improved. To determine the appropriate level of precision fitting a clinical situation, Health Care Professionals (HCPs) should preferably validate the different possible mappings.

Referanser

Stetson PD, Morrison FP, Bakken S, Johnson SB. Preliminary development of the physician documentation quality instrument. J.Am.Med.Inform.Assoc. 2008;15:534-41.

Kalra D, Ingram D. Electronic health records. Information Technology Solutions for Healthcare 2006:135-181.

Eccher C, Purin B, Pisanelli DM, Battaglia M, Apolloni I, Forti S. Ontologies supporting continuity of care: The case of heart failure. Comput.Biol.Med. 2006;36(7- 8):789-801.

Sundvall E, Qamar R, Nyström M, Forss M, Petersson H, Karlsson D, et al. Integration of tools for binding archetypes to SNOMED CT. BMC Medical Informatics and Decision Making 2008;8(Suppl 1):S7.

Cimino JJ. Desiderata for controlled medical vocabularies in the twenty-first century. Methods Inf.Med. 1998;37:394-403.

Chute CG, Cohn SP, Campbell JR. A framework for comprehensive health terminology systems in the United States: development guidelines, criteria for selection, and public policy implications. ANSI Healthcare Informatics Standards Board Vocabulary Working Group and the Computer-Based Patient Records Institute Working Group on Codes and Structures. J.Am.Med.Inform.Assoc. 1998;5:503-10.

Elkin PL, Brown SH, Carter J, Bauer BA, Wahner- Roedler D, Bergstrom L, et al. Guideline and quality indicators for development, purchase and use of controlled health vocabularies. Int J Med Inform 2002;68:175-86.

Rosenbeck KH. Deling, genbrug og standardisering af Sundhedsfagligt Indhold - Brobygning i det danske EPJlandskab. Specialeprojekt fra Institut for Sundhedsvidenskab og Teknologi 2009.

Andersen P,Lindgaard A. Strukturering og standardisering af sygeplejefaglig dokumentation indenfor ernæring vha. SNOMED CT. Specialeprojekt fra Institut for Sundhedsvidenskab og Teknologi 2009.

Cornet R,de Keizer N. Forty years of SNOMED: a literature review. BMC Med.Inform.Decis.Mak. 2008;8 Suppl 1:S2.

Brown,SH.Rosenbloom,ST.;Bauer,BA.;Wahner- Roedler,D.;Froehling,DA.;Bailey,KR.;Lincoln,MJ; Montella,D.;Fielstein,EM.;Elkin,PL.Direct Comparison of MEDCIN® and SNOMED CT® for Representation of a General Medical Evaluation Template. : AMIA; 2007.



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