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MMEx uses SNOMED CT in the presenting complaint field in the progress note, the medical history of a patient and Australian Medicines Terminology for recording allergies. The objective of using terminology databases is to facilitate the accurate recording and sharing of clinical and related health information, improved consistency of data recording in health records and support for integrated decision support tools.
Explain it to me in 15 seconds…
MMEx uses standardised clinical terminology databases to support specific functionality and to assist users with recording data in a way that is easier to report on.
Clinical databases used include:
To use a Coded field:
SNOMED CT is a clinical terminology with global scope covering a wide range of clinical specialties, disciplines and requirements. As a result of its broad scope, one of the benefits of SNOMED CT is a reduction of specialty boundary effects that arise from use of different terminologies or coding systems by different clinicians or departments.
Benefits of SNOMED CT:
Australian Medicines Terminology is a national, standards-based approach to the identification and naming of medicines in clinical systems for Australia.The AMT has been primarily developed to be used in clinical software applications to facilitate interoperability between systems. It can be used by knowledge resource developers, clinicians, researchers, statistical users, government agencies, healthcare organisations and consumers.
The AMT uniquely identifies and accurately describes medicines in a standardised format using a set of defining properties. Some of these properties include active ingredient(s), product trade name, dosage form, strength, pack size and container type.
Benefits of AMT:
Selecting record medical conditions from SNOMED CT and allergies from Australian Medicines Terminology forms one part of the decision support capabilities of MMEx.
When allergies are selected using Australian Medicines Terminology users who are prescribing medications for example, will receive warnings if they are about to prescribe a medication that contains something the patient is allergic to.
Using SNOMED CT to record medical history items and presenting complaints also improves the reporting capability of your organisation. Data is more easily able to be analysed if it is recorded in a consistent manner. Your reporting team will not have to individually select each possible spelling (including typos) and entry style (capitals, lowercase, mixed) of a word if information has been entered free text.
With presenting complaints or subjects selected from SNOMED you will more easily be able to identify frequency of presentation types and analyse the type of work that you are undertaking.
This may not seem particularly important, but if you do the reporting and data analysis for your organisation, it is vital and saves many hours of work for each report.
In order to search effectively in a terminology database, searching by the concept, not necessarily the obvious term will present more accurate results. You need to be sure that the term / synonym you use is an accurate representation of what you mean. A concept may be expressed in the terminology database using words that are different to the ones you are searching for – you may need to think laterally and paraphrase to find what you want.
You have the option of typing into the field and selecting from the filtered drop down list or click on more to see every possibly related option.
Many users find the drop down list less confusing.
For example purposes, we will look at the presenting complaint section in the progress note that utilises the SNOMED CT database. Start by typing in a concept and pause, the list will appear from where you can make a selection.
In this example the patient presents with pain in his back. As you can see in the diagram below, by typing in “pain in”, it brings up a list of associated terms, but not necessarily the accurate description.
A more accurate way of searching for this complaint will be to type in “back pain”; This brings up a much more accurate list.
The key is to search for a specific concept and narrow down the options to what you are searching for.
Medical History also uses the SNOMED CT data base.
When searching for a medical history item, you will see many variants in the naming of the condition.
In this example Diabetes, when you type the start of the condition name you will see the list of sub-items related to the main item. You can select any of these for accuracy of recording the condition.
When it comes to reporting, your data manager can select to filter a report by “Diabetes Mellitus” and all sub-items will be selected automatically to ensure that all related conditions are captured.
Allergies utilises the Australian Medicines Terminology database.
When selecting an allergy you may select foods and other allergens from the list, being as specific as required.
You can also select medication allergies.
In this example I have searched for penicillin.
The list gives the options to select “Penicillins” as a group of medications that the patient is allergic to, or one derivative of penicillin eg “Penicillamine” if I wish to or need to be more specific.