REVIEW – November 2011

SNOMED CT as an instrument for formation of electronic patient record

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Abstract

The SNOMED CT is an instrument for encoding clinical data from the patient`s medical history. The structure of the nomenclature seeks a way to preserve the richness of expression of free text while providing an opportunity for processing clinical data by means of modern information technologies. Computer technology opens up possibilities for learning from own experience, for clinical research, and for improvement of the the quality of care. Automated cross-mapping systems can significantly reduce the time needed for routine treatment of statistical and billing information. Clinical nomenclature is a complex structure and its use requires special training for the encoding specialist.