Compliance content - Request for input

Clinical Reference Groups Nursing CRG
1

Hi all,

SNOMED CT includes both finding and observable concepts in relation to compliance. Examples:

  • 1156280004 |Compliance behavior to exercise regime (observable entity)|
  • 704662005 |Noncompliance with exercise regimen (finding)|
  • 1156279002 |Complies with exercise regime (finding)|

While neither hierarchy has a significant amount of content, the Observable entity hierarchy has a slightly broader range of content and includes concepts such as 1148842005 |Compliance behavior to social norm (observable entity)| whereas the Finding hierarchy focuses on treatment compliance.

It is understood that in the context of an assessment an Observable entity concept would be required and if used for documenting e.g. progress notes, then is a Finding concept would be necessary.

Input is being requested from the Nursing CRG as to whether there is preference for Clinical finding concepts or Observable entity concepts to support clinical documentation.

Please add your comments here.

Thank you.

2

Summary of October Nursing CRG discussion (taking from recording as I wasn’t present on the call):

Value of both findings and observables were noted from both a documentation perspective as well as allowing for differences in systems.

Approach of using both is problematic as there are at least two ways to capture the information.

  • The finding only approach captures the meaning independent of the way it was elicited and the meaning is represented in one concept- the model of meaning approach.
  • The observable approach the semantics is captured across two concepts - a question is asked and a response given, with the response often being a single word or phase e.g. false, raised etc. With the latter there is more than one way to ask the question and get the same response.
  • Concern was raised as the ability to compare these representations computably as equivalent was an issue.

While raised in this topic, this issue is relevant more generally. There needs to be:

  • Clear documentation to let users, analysts etc know that there is more than one way to capture the information
  • Ways to reconcile these different representations

LOINC does not have observable content on compliance from a nursing perspective.

Thank you for the input provided. These responses will be taken back for internal discussion.