However, with the emergence of the electronic health record (EHR) the use of SNOMED CT is now being driven by health policy. In some countries such as England its use is mandated.
SNOMED CT is the world’s most comprehensive terminology for electronic health information – it underpins the EHR by allowing information to be recorded using the same language.
This has multiple benefits, allowing clinicians to record and compare interventions across organisations and sectors, supporting more effective analysis of data and research, and importantly its use improves patient safety and supports clinical decision making.
The Society has started a long term project to support physiotherapists in the use of SNOMED CT subsets. The first subsets have now been developed and published and are designed for use to underpin the EHR in any clinical setting.
The following subsets were released in April 2016:
- Deformity of spine findings
- Joint movement findings
- Mobility findings
- Musculoskeletal reflex findings
- Pain aggravating factors
- Pain easing factors
- Posture findings
- Spine movement findings
- Transfer ability findings
- Wound integrity findings
The subsets and supporting guidance can be found in this document, as well as the links to the full SNOMED CT repository hosted by the Health and Social Care Information Centre via the Data Dictionary for Care (DD4C).
The CSP welcomes feedback on any of its SNOMED CT subsets based on review and usage so that the subsets can remain up to date and implementable. It also welcomes contact from those who might wish to participate in evaluation and review of SNOMED CT subsets in development. If you wish to participate or have any feedback then please email Sue Hayward-Giles.
The CSP will continue working with members to develop further subsets, however recognising that many clinicians are not yet using EHRs the following information outlines the CSP’s position on the use of short forms.
Developing and using short forms
The main reason healthcare professionals want to use short forms in clinical practice is to improve efficiency when making entries to patient records.
Therefore, without the use of short forms, significant extra time may be required to write entries in full.
Also, in specialist units, short forms can be developed as part of a common language used to facilitate faster communication between individual professions and multi-disciplinary groups.
The other reason short forms remain popular is that they help to save space used to communicate interactions with patients, thereby making the record as succinct as possible to read or view.
CSP position on the use of short forms
Physiotherapy staff need to recognise that the language they use must be understood by other health professionals.
Furthermore, they need to understand that patients have the right of access to, and to an explanation of, their record under the Data Protection Act, thus bringing the use of short forms under further scrutiny.
The CSP acknowledges that its members face significant risks with using short forms in health records.
However (alongside the HCPC and other national NHS IT programmes) it also understands that the use of short forms is common practice in the profession, and a pragmatic line needs to be taken on this issue that supports its members to mitigate the risks associated with using short forms.
The CSP has developed the following position:
- Use SNOMED terms, where they exist
- Members should only use short forms if there is an agreed list developed locally that is accessible to anyone entering information into, or viewing, health records
- If records are being transferred elsewhere, the agreed list must be transferred with the record to aid subsequent understanding of the short forms that appear in the record
- Physiotherapy staff should work with system suppliers to incorporate good practice around the use of short forms in record keeping templates to facilitate accurate, speedy entry, and to stipulate that, for sharing, review or printing of the record, the short form is fully described
- Educators within the profession need to highlight both the risks associated with, and good practice relating to, the use of short forms in pre and post registration training for physiotherapists, and in training for support workers
- The CSP will maximise any opportunity presented to lobby for a national set of agreed multidisciplinary common short forms that can be universally implemented in paper-based or electronic record keeping systems, for example NHS, HIV etc. Where electronic, this should be based on existing national terminology in electronic record keeping systems
Use of short forms: good practice
Whilst many health care professionals and their managers recognise the risks associated with using short forms, they have developed pragmatic approaches to managing the level of risk by implementing some or all of the following:
- Educating staff about the risks involved in using short forms and the potential consequences when misuse occurs
- Requiring teams to develop their own standardised list of accepted short forms with associated definitions of the clinical or management term they are describing; for example, an entry to such a list might read as follows:
- Clinical term: Active Cycle of Breathing Technique
- Abbreviation: (suggested): act cyc br tech
- Initialisation: ACBT
- Concept: the use of a consistent approach to breathing through the combination of use of lower thoracic expansion exercises, the forced expiratory technique and further lower thoracic expansion exercises