SNOMED-CT as a standardized language system model for nursing: an integrative review / SNOMED-CT como modelo de sistema de lenguaje estándar para enfermería: revisión integradora / SNOMED-CT como modelo de sistema de linguagem padronizada à enfermagem: revisão integrativa

ABSTRACT Objective: To describe the use of the Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) as a model for interoperability of the nursing terminology in the national and international contexts. Methods: This is an integrative literature review according to Cooper, which searched for articles in Portuguese, English and Spanish, published between September 2011 and November 2018 in the BVS, PubMed, SCOPUS, CINAHL, EMBASE, and Web of Science databases, ending in a sample of 15 articles. Results: The SNOMED-CT is a multi-professional nomenclature used by nursing in different care contexts, being associated with other standardized languages of the discipline, such as ICNP®, NANDA-I, and the Omaha System. Conclusion: This review has shown that the use of SNOMED- CT is incipient in the national context, justifying the need to develop studies aimed at mapping the interoperability of existing systems of standardized language, especially NANDA-I, ICNP and Omaha System, in order to adapt the implementation of SNOMED-CT.

RESUMEN Objetivo: Describir el uso de Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) como modelo de interoperabilidad de las terminologías de enfermería en el contexto nacional e internacional. Metodología: Se trata de revisión integradora de la literatura según Cooper, que buscó estudios en portugués, inglés y español, publicados entre septiembre de 2011 y noviembre de 2018 en las bases de datos BVS, PubMed, SCOPUS, CINAHL, EMBASE y Web of Science, que culminó en una muestra de 15 artículos. Resultados: SNOMED-CT es una nomenclatura multiprofesional empleada por la enfermería en diferentes contextos de cuidado, asociado a otros lenguajes estandarizados de enfermería como CIPE®, NANDA-I y Omaha System. Conclusión: Esta revisión demostró que el uso de SNOMED-CT es incipiente en el contexto nacional, lo que justifica la necesidad de desarrollar estudios destinados a mapear los sistemas de lenguajes estandarizados existentes, especialmente NANDA-I, CIPE y Omaha System, con el propósito de adaptar la implementación de SNOMED-CT.

RESUMO Objetivo: Descrever a utilização do Systematized Nomenclature of Medicine - Clinical Terms (SNOMED-CT) como modelo de interoperabilidade das terminologias da enfermagem no contexto nacional e internacional. Metodologia: Trata-se de revisão integrativa da literatura segundo Cooper, que buscou artigos em português, inglês e espanhol, publicados entre setembro de 2011 a novembro de 2018 nas bases de dados BVS, PubMed, SCOPUS, CINAHL, EMBASE e Web of Science, finalizando em uma amostra de 15 artigos. Resultados: O SNOMED-CT é uma nomenclatura multiprofissional utilizada pela enfermagem em diferentes contextos de cuidado, sendo associada com outras linguagens padronizadas da disciplina, como CIPE®, NANDA-I e Omaha System. Conclusão: Esta revisão mostrou que o uso do SNOMED-CT é incipiente no contexto nacional, justificando a necessidade de desenvolvimento de estudos visando o mapeamento dos sistemas de linguagem padronizadas existentes, especialmente a NANDA-I, CIPE® e Omaha System, para fins de adequar a implementação do SNOMED-CT.

Computer-based clinical coding activity analysis for neurosurgical terms / 영남의대학술지

BACKGROUND: It is not possible to measure how much activity is required to understand and code a medical data. We introduce an assessment method in clinical coding, and applied this method to neurosurgical terms.METHODS: Coding activity consists of two stages. At first, the coders need to understand a presented medical term (informational activity). The second coding stage is about a navigating terminology browser to find a code that matches the concept (code-matching activity). Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) was used for the coding system. A new computer application to record the trajectory of the computer mouse and record the usage time was programmed. Using this application, we measured the time that was spent. A senior neurosurgeon who has studied SNOMED CT has analyzed the accuracy of the input coding. This method was tested by five neurosurgical residents (NSRs) and five medical record administrators (MRAs), and 20 neurosurgical terms were used.RESULTS: The mean accuracy of the NSR group was 89.33%, and the mean accuracy of the MRA group was 80% (p=0.024). The mean duration for total coding of the NSR group was 158.47 seconds, and the mean duration for total coding of the MRA group was 271.75 seconds (p=0.003).CONCLUSION: We proposed a method to analyze the clinical coding process. Through this method, it was possible to accurately calculate the time required for the coding. In neurosurgical terms, NSRs had shorter time to complete the coding and higher accuracy than MRAs.

Systematized verrucous epidermal nevus partially responsive to acitretin: A case report

@#<p style="text-align: justify;">A 5-year-old female presented a 4-year history of generalized well-demarcated asymptomatic brown to dark brown thin verrucous plaques with a Blaschkoid distribution. Histopathology was consistent with an epidermal nevus. Patient was diagnosed to have systematized verrucous epidermal nevus. Due to the extent of the lesions, surgical management was not feasible. Hence acitretin was given which showed partial decrease in the thickness of the lesions.</p>

Understanding new progress in prosthodontics from the perspective of updates in the glossary of prosthodontic terms / 中华口腔医学杂志

Glossary of Prosthodontic Terms is a standardized vocabulary with international influence. Its ninth edition was published in J Prosthet Dent in 2017, 12 years after the last edition. During this period, great development has taken place in the dental prosthetics due to dental implant and digital dentistry as well as application of new materials and technologies. The research results of dental adhesion, aesthetic dentistry, orofacial function, and tissue regeneration has been fully applied in dental clinic. This paper attempts to capture and accurately understand the changes of some important, especially controversial academic concepts through the comparison of the seventh, eighth and ninth edition of vocabulary. Four parts including new terms, obsolete terms, terms with updated concept, and terms with the continuity of concept are used to show the important progress of prosthodontics.

A Case of Systematized Nevus Sebaceous / 대한피부과학회지

A patient with nevus sebaceous showing linear or wide distribution can present with a triad of nevus sebaceous, seizures, and mental retardation. Most of those cases are classified as sebaceous nevus syndrome. Ophthalmological, skeletal, and other abnormalities may also be present. A male weighing 3,580 g was born at the gestational age of 38 weeks after a normal pregnancy. He was referred to the dermatologic department on the first day of life. He presented with yellow-orange and verrucous plaques on both sides of the temporal areas, face, neck, upper and lower extremities, and trunk. Skin biopsy specimens were taken from the scalp and right lower leg. Histologically, both specimens showed sebaceous gland hyperplasia, absence of mature hair follicles, infundibular cystic structures, and apocrine glands. Brain magnetic resonance imaging, transthoracic echocardiography, abdomen ultrasonography, and routine laboratory investigations were performed and showed nonspecific findings. The patient did not show seizure activity at 19 days of observation, and he is now on close observation. We herein report a very rare case of systematized nevus sebaceous presenting at birth.

Critical analysis and systematization of rat pancreatectomy terminology

ABSTRACT PURPOSE: To critically analyze and standardize the rat pancreatectomy nomenclature variants. METHODS: It was performed a review of indexed manuscripts in PUBMED from 01/01/1945 to 31/12/2015 with the combined keywords "rat pancreatectomy" and "rat pancreas resection". The following parameters was considered: A. Frequency of publications; B. Purpose of the pancreatectomy in each article; C. Bibliographic references; D. Nomenclature of techniques according to the pancreatic parenchyma resection percentage RESULTS: Among the 468, the main objectives were to surgically induce diabetes and to study the genes regulations and expressions. Five rat pancreatectomy technique references received 15 or more citations. Twenty different terminologies were identified for the pancreas resection: according to the resected parenchyma percentage (30 to 95%); to the procedure type (total, subtotal and partial); or based on the selected anatomical region (distal, longitudinal and segmental). A nomenclature systematization was gathered by cross-checking information between the main surgical techniques, the anatomic parameters descriptions and the resected parenchyma percentages. CONCLUSION: The subtotal pancreatectomy nomenclature for parenchymal resection between 80 and 95% establishes a surgical parameter that also defines the total and partial pancreatectomy limits and standardizes these surgical procedures in rats.

Usage Patterns of Nursing Diagnoses among Student Nurses in Psychiatric Unit: Relation with NANDA and SNOMED CT / 정신간호학회지

PURPOSE: The aim of this study was to explore how nursing diagnoses are made by undergraduate students of psychiatric unit in Korea. METHODS: Data were collected from case reports and analyzed based on NANDA (North American Nursing Diagnosis Association) nursing diagnoses and Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) as reference terminology. RESULTS: The 30 different nursing diagnoses from 135 distinct nursing diagnosis statements were assessed after removing repetition of case studies from a of total of 1,140 statements of nursing diagnoses. The most frequently used NANDA diagnosis was "ineffective coping" The thirty nursing diagnoses were grouped under 10 out of the 13 NANDA domains. In addition, 98 related factors were classified into SNOMED CT hierarchies of Clinical Finding, Procedure, and Observable Entity. The content validity index for the mapping of nursing diagnoses was 0.97, indicating a relatively strong agreement. CONCLUSION: These results can help students to improve their knowledge and better formulate appropriate diagnoses. Using standardized terminology would improve competency of education and help to ratify the steps of the nursing process, especially nursing planning. Educational strategies that enhance diagnostic accuracy are recommended.

Manejo y resultados quirúrgicos de fracturas diafisiarias de antebrazo en el adulto aplicando una base de datos sistematizada traumatológica / Surgical management and results diaphyseal forearm fracture in the adult applying a trauma database systematized

Se realiza un estudio abierto, observacional, descriptivo, tipo serie clínica en el IAHULA, Mérida, Venezuela, en pacientes adultos tratados quirúrgicamente por fracturas de antebrazo durante el 2012, se vaciaron en una base de datos sistematizada traumatológica, HICLINEL ®, demostrando su eficacia y utilidad. Se incluyeron 40 pacientes, 42 casos. 85% pacientes y 85,7% casos fueron controlados. 82,5% de sexo masculino. Edad promedio 29,4 años. 25% obreros. 45% por hechos viales en moto. 16,7% fueron fracturas 22A3.2. 100% tratados mediante reducción directa, 97,5% se realizo osteosíntesis con placa. 100% y 91,2% tuvieron escalas de MAYO excelente para codo y muñeca, respectivamente. 88,9% tuvo consolidación total. 8,8% presentaron complicaciones. En el manejo de estas fracturas en nuestra institución el implante de elección son las placas rectas de pequeños fragmentos bajo una reducción directa, obteniéndose resultado funcionales postoperatorios excelentes con consolidación completa. El HICLINEL® se sometió a valoración, generando datos estadísticos con buen desempeño(AU)

We performed an open-type series per se clinic in IAHULA, Merida, Venezuela, with adult patients surgically treated for forearm fractures during 2012, which were emptied into a trauma database systematized HICLINEL ® demonstrating their effectiveness and usefulness. We included 40 patients, 42 cases. 85% and 85,7% cases patients were monitored. Male 82,5%. Average age of 29.375 years. 25% workers. 45% by road motorcycle events. 22A3.2 16,7% were fractures. 100% were treated by direct reduction, 97,5% were performed plate fixation. 100% and 91,2% MAYO scales had excellent elbow and wrist, respectively. 88,9% was full consolidation. 8,8% had complications. In the management of diaphyseal forearm fractures in our institution the implant of choice are straight plates of small fragments under direct reduction, obtaining excellent postoperative functional outcome with their complete consolidation. HICLINEL ® system underwent assessment with the ability to generate statistical data, showing a good performance(AU)

Comparison of Knowledge Levels Required for SNOMED CT Coding of Diagnosis and Operation Names in Clinical Records / 대한의료정보학회지

OBJECTIVES: Coding Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT) with complex and polysemy clinical terms may ask coder to have a high level of knowledge of clinical domains, but with simpler clinical terms, coding may require only simpler knowledge. However, there are few studies quantitatively showing the relation between domain knowledge and coding ability. So, we tried to show the relationship between those two areas. METHODS: We extracted diagnosis and operation names from electronic medical records of a university hospital for 500 ophthalmology and 500 neurosurgery patients. The coding process involved one ophthalmologist, one neurosurgeon, and one medical record technician who had no experience of SNOMED coding, without limitation to accessing of data for coding. The coding results and domain knowledge were compared. RESULTS: 705 and 576 diagnoses, and 500 and 629 operation names from ophthalmology and neurosurgery, were enrolled, respectively. The physicians showed higher performance in coding than in MRT for all domains; all specialist physicians showed the highest performance in domains of their own departments. All three coders showed statistically better coding rates in diagnosis than in operation names (p < 0.001). CONCLUSIONS: Performance of SNOMED coding with clinical terms is strongly related to the knowledge level of the domain and the complexity of the clinical terms. Physicians who generate clinical data can be the best potential candidates as excellent coders from the aspect of coding performance.

Padrões de dados, terminologias e sistemas de classificação para o cuidado em saúde e enfermagem / Data standards, terminology and classification systems for caring in health and nursing / Patrones de datos, terminología y sistemas de clasificación en atención de la salud y de enfermería

A informação é essencial para o cuidado de Enfermagem, pois subsidia o enfermeiro na tomada de decisão clínica para a resolução e diminuição dos problemas em saúde. Este estudo de revisão integrativa identificou nas publicações de periódicos nacionais e internacionais os principais padrões de dados, terminologias e sistemas de classificação utilizados no cuidado em saúde e Enfermagem. A pesquisa foi realizada nas bases de dados MEDLINE, CINAHL e SCIELO utilizando os descritores: Sistemas de Informação, Informática em Enfermagem, Informática Médica, Sistemas Computadorizados de Registros Médicos, Terminologia e Nomenclatura Sistematizada de Medicina. Foram selecionados 91 artigos sendo analisados em duas categorias empíricas: "padrões de dados para o cuidado em saúde e enfermagem" e "terminologias e sistemas de classificação em Enfermagem". A partir dos diversos padrões de dados, terminologias e sistemas existentes, considera-se importante que a Enfermagem se aproprie dos mesmos visando aprimorar e renovar a qualidade do cuidado.

Information is essential for nursing care because nurses in subsidizing clinical decision making for the resolution and reduction of health problems. This review integrative study identified publications in national and international journals the major data standards, terminologies and classification systems used in health care and nursing. The research was conducted on MEDLINE, CINAHL and SCIELO using the keywords: Information Systems, Nursing Informatics, Medical Informatics, Computerized Medical Records Systems, Terminology and Nomenclature of Medicine Systematized. It was selected 91 articles which were analyzed in two empirical categories: "data standards for health care and nursing" and "terminologies and classification systems in nursing" From the various data standards, terminologies and classification systems, it is important that nursing take ownership of them aiming to improve and renew the quality of care.

La información es esencial para el cuidado de enfermería, apoyando las enfermeras en la de toma de decisiones clínicas para la resolución y la reducción de problemas de salud. Este estudio, de revisión integrativa, identificó las publicaciones en revistas nacionales y las principales normas internacionales de datos, terminologías y sistemas de clasificación utilizados en la atención médica y de enfermería. La investigación fue realizada en MEDLINE, CINAHL y SCIELO utilizando las palabras clave: Sistemas de Información, Informática en Enfermería, Informática Médica Computadorizada, Sistemas de Registros Médicos, Terminología y Nomenclatura Sistematizada de Medicina. Se seleccionaron 91 artículos, analizados en dos categorías empíricas: "las normas de datos para la atención médica y de enfermería" y "terminologías y sistemas de clasificación de la enfermería". De las normas de diversos datos y terminologías y clasificación existen, es importante que la enfermería tomar posesión de ellas destinadas a mejorar y renovar la calidad de la atención.

Nomenclatura dos fatores do sistema HLA / Nomenclature for factors of the HLA system

The Nomenclature Committee for Factors of the HLA System of the World Health Organization standardizes the nomenclature of the HLA system and meets regularly during the International Histocompatibility Workshops. During the 15th International Histocompatibility Workshop in Buzios (RJ), Brazil, in September 2008, there was a meeting of the nomenclature committee when new rules were established, whichwere implemented in April 2010.

O Comitê de Nomenclatura dos Fatores do Sistema HLA da Organização Mundial da Saúde normatiza a nomenclatura do sistema HLA e se reúne regularmente durante os Workshops Internacionais de Histocompatibilidade. Durante o 15o Workshop Internacional de Histocompatibilidade, em Búzios (RJ), em Setembro de 2008, houve a reunião do comitê de nomenclatura, quando novas regras foram estabelecidas, sendo implantadas em Abril de 2010.

Exploring the Possibility of Information Sharing between the Medical and Nursing Domains by Mapping Medical Records to SNOMED CT and ICNP / 대한의료정보학회지

OBJECTIVES: The purpose of this study is to explore possibility of information sharing between the medical and nursing domains. METHODS: Narrative medical records of 281 hospitalization days of 36 gastrectomy patients were decomposed into single-meaning statements. These single-meaning statements were combined into unique statements by removing semantically redundant statements. Concepts from the statements describing patients' problem and medical procedures were mapped to Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) and International Classification for Nursing Practice (ICNP) concepts. RESULTS: A total 4,717 single-meaning statements were collected and these single-meaning statements were combined into 858 unique statements. Out of 677 unique statements describing patients' problems and medical procedures, about 85.5% statements were fully mapped to SNOMED CT. The remaining statements were partially mapped. In the mapping to the ICNP concepts, 17.4% of unique statements were fully mapped, 62.8% were partially mapped, and 19.8% were not mapped. About 32.3% of 705 concepts extracted from the statements were mapped to both SNOMED CT and ICNP concepts. CONCLUSIONS: These mapping results suggest that physicians' narrative medical records can be structured and can be used for electronic medical record system, and also it is possible for medicine and nursing to share patient care information.

Proposed Algorithm with Standard Terminologies (SNOMED and CPT) for Automated Generation of Medical Bills for Laboratory Tests / 대한의료정보학회지

OBJECTIVES: In this study, we proposed an algorithm for mapping standard terminologies for the automated generation of medical bills. As the Korean and American structures of health insurance claim codes for laboratory tests are similar, we used Current Procedural Terminology (CPT) instead of the Korean health insurance code set due to the advantages of mapping in the English language. METHODS: 1,149 CPT codes for laboratory tests were chosen for study. Each CPT code was divided into two parts, a Logical Observation Identifi ers Names and Codes (LOINC) matched part (matching part) and an unmatched part (unmatched part). The matching parts were assigned to LOINC axes. An ontology set was designed to express the unmatched parts, and a mapping strategy with Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) was also proposed. Through the proceeding analysis, an algorithm for mapping CPT with SNOMED CT arranged by LOINC was developed. RESULTS: 75% of the 1,149 CPT codes could be assigned to LOINC codes. Two hundred and twenty-five CPT codes had only one component part of LOINC, whereas others had more than two parts of LOINC. The system of LOINC axes was found in 309 CPT codes, scale 555, property 9, method 42, and time aspect 4. From the unmatched parts, three classes, 'types', 'objects', and 'subjects', were determined. By determining the relationship between the classes with several properties, all unmatched parts could be described. Since the 'subject to' class was strongly connected to the six axes of LOINC, links between the matching parts and unmatched parts were made. CONCLUSIONS: The proposed method may be useful for translating CPT into concept-oriented terminology, facilitating the automated generation of medical bills, and could be adapted for the Korean health insurance claim code set.

Developing a Reference Terminology Model for Health Care Using an Object-Oriented Approach / 대한의료정보학회지

OBJECTIVE: A reference terminology is essential to achieve semantic interoperability and enhance the quality of health care. Reference terminologies that have achieved common acceptance contain many concepts that clinicians would not want in healthcare, which preclude their practical use in documentation of patient information. To solve the problems, this document proposes a reference terminology model which contains concepts that physicians can use satisfactorily. METHODS: We analyzed the structures of the UMLS and SNOMED CT. We also analyzed health care terms which had been collected by the Korea National Health Information Standard Committee. Based on the results of the analysis, we developed an object-oriented reference terminology model. And, we designed database schema with the model. RESULTS: Eight components of the UMLS and six components of the SNOMED CT were analyzed. The collected terms had various properties and mapping vocabularies according to the characteristics of their respective domains. A reference terminology model was developed from a three-level view using UML. A database schema was developed using ERD. CONCLUSION: This study mainly focuses on reference terminology modeling. It is hoped that this reference terminology modeling helps the semantic interoperable exchange of clinical documents as the basis of common EMR.

Systematized Laparoscopic Surgery in Abdominal Trauma

With the wide spread of laparoscopic procedures in surgery, laparoscopy has been revived as a diagnostic and therapeutic modality in blunt and penetrating abdominal trauma. From August 1995 to November 1996, we applied therapeutic laparoscopy to 15 hemodynamically stable patients with abdominal trauma, including 10 (66%) blunt and 5 (34%) penetrating injuries. The mean age of the patients was 35 (17~64) years. All were male, except for one female patient. Organs injured were 4 single perforations, 1 multiple perforation and 1 complete transsection of the small bowel; 2 mesenteric tearings with small bowel ischemia; 2 stomach perforations; 2 mesenteric lacerations; 2 omental lacerations; and 1 liver laceration. Patients with unstable vital signs, or solid organ or retroperitoneal injury were excluded by conventional diagnoses. Laparoscopic abdominal exploration was initiated by changing the position to the Trendelenburg position for evaluation of the pelvic cavity and lower-1/3 of the small bowel, to the supine position for evaluation of the mid-abdomen and mid-1/3 of the small bowel, and to the reverse Trendelenburg for evaluation of the liver, spleen, pancreas, and upper 1/3 of the small bowel. Operation methods consisted of totally laparoscopic or laparoscopic-assisted techniques in 11 cases (73.3%) and 4 cases (26.7%), respectively. Hence, we were able to reduce the rate of open surgery in 11 (73.3%) of the 15 patients who were thought to need operative treatment, 14 of whom needed actual surgical intervention (One pre-operatively undetected liver laceration revealed spontaneous ceasation of bleeding at the time of laparoscopic examination). The mean operation time was 110 min per case (113 min and 100 min for totally laparoscopic surgery and laparoscopic-assisted surgery, respectively). Flatus passed at the 2.4 (mean) post-operative day. The patients started meals at the 3.3 (mean) post-operative day and were discharged at the 7 (mean) post-operative day uneventfully. The only exception was one wound infection in the laparoscopic-assisted group. Conclusively, sytematized laparoscopic surgery is a feasible, safe, and effective procedure for the treatment of abdominal trauma.

Systematized Epidermal Nevi Associated with Congenital Alopecia Universalis and Onychodystrophy

We report a case of a 25-year-old woman with systematized epidermal nevi associated with alopecia universalis and onychodystrophy. The histopathologic examinations by light and electron microscopies of the epidermis of the trunk and scalp lesions showed epidermal nevus with characteristic features of epidermolytic hyperkeratosis. This is a rare case of systematized epidermal nevi associated with congenital alopecia universalis and onychodystrophy. Though there is no apparent gross skin lesion on the hair bearing area, the development of epidermal nevi can affect the hair and nail units which are derived from the common epidermal germinative cells.