SNOMED CT Editorial Guide

Version: Date:
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Table of Contents

SNOMED CT Introduction 4
4
Intended Use 4
Scope 5
Semantic Interoperability 12

Concept Model Overview 14

Root and Top-level Concepts 14
Subtype Relationships 15
Attributes 16
Defining Characteristics 18
Qualifying Characteristics 18

Authoring 20
Modeling philosophy of SNOMED CT 20
Advantages of the approach 20
Content that does not conform 20
Authoring information 20
Does It Belong In SNOMED CT? 20
Descriptions 27
General Naming Conventions 36
General Modeling 48
Domain Specific Modeling 67

Appendices 253
Appendix A: SNOMED CT Requirements 253
Appendix B: Concept Models 269
Appendix C: Principles for Accepting Content in the International Release 276
Appendix D: Historical Notes 279
Appendix E: Editorial Guide: Style and Terms 280

Previous Versions 284

The most recently updated pages in this document are listed below 285

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These guidelines should be applied to new content. While there are many terms in the existing content that
are not in compliance with this guidance, the process of correcting existing content will be carried out as time
and resources permit.
The Editorial Guide provides the information necessary to model terms in SNOMED CT. It is for those who edit
content in the International Release, but it may also be useful to those creating extensions. It is a working
document, subject to change and revision.
SNOMED CT is distributed in sets of electronic files. Supporting software tools are not necessarily provided
directly by SNOMED International.

July 2020 International Release

Web browsable version: http://snomed.org/eg
SNOMED CT Document Library: http://snomed.org/doc
Summary of changes since last release: https://docs.google.com/spreadsheets/d
/1xHZNeNQwkCcUPaZGEl28GFGv_WMTHZoeHeAV5cSjOFU/

© Copyright 2020 International Health Terminology Standards Development Organisation, all rights reserved.
This document is a publication of International Health Terminology Standards Development Organisation, trading
as SNOMED International. SNOMED International owns and maintains SNOMED CT®.
Any modification of this document (including without limitation the removal or modification of this notice) is
prohibited without the express written permission of SNOMED International. This document may be subject to
updates. Always use the latest version of this document published by SNOMED International. This can be viewed
online and downloaded by following the links on the front page or cover of this document.
SNOMED®, SNOMED CT® and IHTSDO® are registered trademarks of International Health Terminology
Standards Development Organisation. SNOMED CT® licensing information is available at http://snomed.org
/licensing . For more information about SNOMED International and SNOMED International Membership, please
refer to http://www.snomed.org (http://www.ihtsdo.org/) or contact us at [email protected] (mailto:[email protected]) .

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SNOMED CT Introduction

What is SNOMED CT?

SNOMED CT is a high-quality, comprehensive, international, logic-based reference terminology that is used to
present clinically relevant information. It began with the union of NHS Clinical Terms Version 3 and SNOMED RT;
this provided the initial scope which has since been updated to reflect contemporary clinical practice and changes
in medical technology.
Content development is provided by expert clinicians driven by the requirements of user communities. This
includes core content for use internationally and content relevant to national extensions for local implementation.
Its logic-based definitions represent terminological knowledge, or what is always true about the meaning of
concepts. It consists of codes, that correspond to concepts, arranged in a polyhierarchical manner, as well as
relationships between the concepts, which further define the meaning.

Description logic
Description logic (DL) is the formal foundation of meaning in SNOMED CT. The way that concepts have
been modeled in SNOMED CT permits them to be represented using description logic. A DL reasoner is
used to classify SNOMED CT. The DL reasoner also helps test expressions for subsumption and
equivalence.

Why use SNOMED CT?

It supports semantic interoperability and multi-purpose use within electronic health applications (primarily
electronic health records or EHRs) and has many advantages over other terminologies. They include:
Consistent, and formal expansion of, content through centralized authoring and maintenance (International
Release)
Flexibility to meet most terminological requirements based on national, regional, language, application, or
customer (Extensions)
Clear, singular meaning of concepts
Reliable, consistent, and reproducible clinical documentation
Enhanced high-quality healthcare delivery to individuals and populations
(See also, Appendix: SNOMED CT Requirements)

Intended Use
SNOMED CT is intended to be used in healthcare:
To provide effective and comprehensive coverage of terms
As a terminological resource
For implementation in electronic health applications
The purpose of SNOMED CT is to represent clinically relevant information reliably and reproducibly in electronic
health applications, (most often electronic health records or EHRs) to support:
Delivery of multidisciplinary, high-quality healthcare to individuals and populations
Optimal retrieval, processing, and rendering of clinical information
Effective use of clinical information consistently and reproducibly

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Use of clinical information for statistical and reporting purposes

Context
Context is an important part of representing clinically relevant information.
When entered in an EHR, concepts in the Procedure and Clinical finding hierarchies have the following
default contexts.
The procedure has actually occurred (versus, e.g. being planned or cancelled) or the finding is
actually present (versus, e.g. being ruled out or considered)
The procedure or finding refers to the patient of record (versus, e.g, a family member)
The procedure or finding is occurring now or at a specified time (versus some time in the past)
When a concept is entered into an EHR, the information in the health record structure or its information
model, can provide the context.
In addition to using the record structure to represent context, there may be a need to override the
defaults and specify a particular context using the formal logic of the terminology. For that reason,
SNOMED CT has developed a context model, i.e Situation with explicit context, to allow users and/or
implementers to specify context using the terminology, without depending on a particular record
structure. The Situation hierarchy, and various attributes assigned to concepts in the hierarchy,
accomplish this.

Guidance for Electronic Health Application Users

Designers and implementers of electronic health applications need guidance to identify which
fields within their record structure will critically affect the meaning of concepts. They require open
strategies to preserve meaning if concepts are retrieved or transferred and to allow detection of
equivalence to constructs derived from alternative approaches.

(see also Situation with Explicit Context section)

Scope
The statement of scope for the International Release is that it includes content necessary for international
conformance and interoperability.
Content that is within the scope of the International Release is restricted to the International Release and may not
be modified or replaced by an extension, unless explicitly permitted by SNOMED International.
SNOMED CT has an international and multilingual scope and can be localized to represent meanings and terms
unique to particular organizations or localities. There are three dimensions to the scope of SNOMED CT:

International release criteria include affirmative answers to the following:

Does it need to be understandable in electronic health applications in more than one national healthcare
system?
Can it be used in electronic health applications beyond a patient's national healthcare system, i.e. if a patient
were to travel or relocate to a different country?
Is it useful in more than one national healthcare system?
A National Extension includes content outside of the scope of the International Release, but necessary for national
conformance and interoperability. Each member-state determines the application and interpretation of this scope
and whether or not concepts should be added to their extension.

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Figure 1: SNOMED CT International Edition and Extensions National Extension criteria include affirmative answers to
the following:
Is the concept outside of the scope of the International Release, but necessary for national conformance and
interoperability?
Is it useful throughout the national healthcare system?
Does it need to be understandable throughout the national healthcare system?
Does it need to be shared in a reproducible manner within the national healthcare system?
If so, then the concept may be eligible for the National Extension.
SNOMED CT is not intended to cover all medical knowledge. Content that is strictly non-human is out of the scope
of SNOMED CT.
Examples of non-human content,
Egg-related coelomitis (disorder)
Dehorning (procedure)
Bone structure of wing (body structure)
Neither does SNOMED CT attempt to capture probabilistic or uncertain knowledge.

Structure of Domain Coverage

SNOMED CT includes 19 domains arranged in a polyhierarchical structure. Each hierarchy is a n ordered
organization of concepts linked together through IS A relationships. Each concept may have one or more parents.
The hierarchical arrangement is helpful for locating concepts, grouping similar concepts, and conveying meaning.
For example, if we see the concept cell under the concept anatomic entity we will understand the intended
meaning as different than if it appeared under the concepts room or power source (Desiderata for Controlled
Medical Vocabularies in the Twenty-First Century by J.J. Cimino published in Methods of Information in Medicine
1998:37:394-403).
Concepts are linked to their more general parent concept codes directly above them in a hierarchy. Concepts with
more general meanings are usually presented as being at the top of the hierarchy and then at each level down the
hierarchy, the meanings become increasingly more specific or specialized.
The domains contain all of the components (clinical, administrative, database structure, as well as other
components that express how the domains relate to each other) necessary to create SNOMED CT concepts and
maintain the database structure.

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Definition Notes Examples

A domain is a set of concepts A domain, to which an The domain of 116676008 | Associated

which the Concept Model permits attribute can be applied, is morphology (attribute) | (http://snomed.info/id
to be defined or refined, using a typically defined to include /116676008) is defined as subtype of
particular set of attributes and concepts in one or more 404684003 | Clinical finding (finding) | (
ranges branches of the subtype http://snomed.info/id/404684003)
hierarchy
Some domains do not have The range of values of 116676008 |
attributes and ranges, but may if a Associated morphology (attribute) | (
concept model is created http://snomed.info/id/116676008) is subtypes
of 49755003 | Morphologically abnormal
structure (morphologic abnormality) | (
http://snomed.info/id/49755003)

The following table lists the domains, definitions, and examples. Those without a Concept Model are marked with
an asterisk.

Domains

Domain/Top-level Hierarchy (alpha-sorted) Examples

1 Body Structure Anatomical or acquired body structure 450807008 | Entire

back (body structure) | (
Morphologic abnormality (subtype of body
http://snomed.info/id
structure)
/450807008)

52988006 | Lesion
(morphologic
abnormality) | (
http://snomed.info/id
/52988006)

2 Clinical Finding Clinical finding: normal/abnormal 39579001 |

observations, judgments, or assessments of Anaphylaxis (disorder) |
patients (http://snomed.info/id
/39579001)
Disorder: always and necessarily an
abnormal clinical state 167222005 | Abnormal
urinalysis (finding) | (
http://snomed.info/id
/167222005)

3 Environment and Environment: types of environments 405607001 |

Geographical Ambulatory surgery
Geographical Location: named locations
Location* center (environment) | (
such as countries, states, or regions
http://snomed.info/id
/405607001)

223581004 | China
(geographic location) | (
http://snomed.info/id
/223581004)

4 Event Occurrences impacting health or health

care; not procedures or interventions

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Domains

242039002 | Abuse of
partner (event) | (
http://snomed.info/id
/242039002)

2641000119104 |
Exposure to chlamydia
(event) | (http://snomed.
info/id/2641000119104)

5 Observable Entity Information about a quality/property to be 423493009 | Age at

observed and how it will be observed diagnosis (observable
entity) | (http://snomed.
info/id/423493009)

416125006 |
Concentration of
hemoglobin in
erythrocyte
(observable entity) | (
http://snomed.info/id
/416125006)

6 Organism Organisms of significance to human and 3265006 | Genus

animal medicine; use in modeling cause of Candida (organism) | (
disease http://snomed.info/id
/3265006)

710877000 | Beta
lactam resistant
bacteria (organism) | (
http://snomed.info/id
/710877000)

7 Pharmaceutical Drug products (not Substances) 400687000 | Infliximab

/Biological Product 100mg/vial powder for
reconstitution
injection (product) | (
http://snomed.info/id
/400687000)

317222006 | Product
containing only
cimetidine 200 mg/1
each oral tablet
(clinical drug) | (
http://snomed.info/id
/317222006)

8 Physical Force* Forces applied to the body that may cause 57955009 | Hot
injury weather (physical
force) | (http://snomed.
info/id/57955009)

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Domains

285719001 |
Mechanical abrasion
(physical force) | (
http://snomed.info/id
/285719001)

9 Physical Object* Physical devices relevant to health care, or 15237007 | Sitz bath
to injuries/accidents chair, device (physical
object) | (http://snomed.
info/id/15237007)

69861004 | Firearm,
device (physical
object) | (http://snomed.
info/id/69861004)

10 Procedure Procedure: activities performed in the 54321008 | Cardiac

provision of health care (includes medical flow imaging
history-taking, physical examination, (procedure) | (
diagnostic and therapeutic interventions, http://snomed.info/id
training and education, and counseling) /54321008)

Regime/therapy (subtype of procedure): set 386513007 |

of procedures focused on a single purpose Anesthesia
on one patient over time (e.g. repeated management (regime
administration of drug in a small dose for /therapy) | (
an indefinite period of time) http://snomed.info/id
/386513007)

11 Qualifier Value* One of several possible values for an 90734009 | Chronic

attribute used to define concepts (qualifier value) | (
http://snomed.info/id
/90734009)

255412001 |
Appearances (qualifier
value) | (http://snomed.
info/id/255412001)

12 Record Artifact* Clinical documents, or parts thereof 445673000 | Original

report (record artifact)
| (http://snomed.info/id
/445673000)

41000179103 |
Immunization record
(record artifact) | (
http://snomed.info/id
/41000179103)

13 Situation with Explicit Concepts that include context information; 169589005 | Antenatal
Context a subtype of the situation to which it care: history of
applies with an attribute associating it with infertility (situation) | (
the relevant clinical finding or procedure http://snomed.info/id
/169589005)

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Domains

May be used to represent conditions 407565004 |

/procedures that already occurred, haven't Angiotensin II receptor
yet occurred, or refer to someone else (not antagonist not
patients) tolerated (situation) | (
http://snomed.info/id
/407565004)

14 SNOMED CT Model Concepts and attributes necessary to 900000000000442005

Component* organize and structure SNOMED CT | Core metadata
terminology and its derivatives concept (core
metadata concept) | (
http://snomed.info/id
/900000000000442005)

900000000000454005
| Foundation metadata
concept (foundation
metadata concept) | (
http://snomed.info/id
/900000000000454005)

106237007 | Linkage
concept (linkage
concept) | (
http://snomed.info/id
/106237007)

370136006 |
Namespace concept
(namespace concept) |
(http://snomed.info/id
/370136006)

15 Social Context* Social conditions and circumstances related 116060000 | Eating

to healthcare habit (life style) | (
http://snomed.info/id
Subtypes include: ethnic group, life style,
/116060000)
occupation, person, racial group, religion
/philosophy, s ocial concept 58626002 | Legal
guardian (person) | (
http://snomed.info/id
/58626002)

415794004 | Unknown
racial group (racial
group) | (http://snomed.
info/id/415794004)

35359004 | Family
(social concept) | (
http://snomed.info/id
/35359004)

16 Special Concept* Inactive and navigational (support locating 363664003 | Erroneous

concepts in hierarchies) concept codes concept (inactive
concept) | (
http://snomed.info/id
/363664003)

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Domains

394899003 | Oral
administration of
treatment
(navigational concept)
| (http://snomed.info/id
/394899003)

17 Specimen* Entities that are obtained (usually from 373193000 | Lymph

patients) for examination or analysis node from sentinel
lymph node dissection
(specimen) | (
http://snomed.info/id
/373193000)

258441009 | Exudate
sample (specimen) | (
http://snomed.info/id
/258441009)

18 Staging and Scales* Assessment and tumor staging scales 273472005 | Functional
status index
(assessment scale) | (
http://snomed.info/id
/273472005)

254294008 | Tumor-
node-metastasis (TNM)
head and neck tumor
staging (tumor staging)
| (http://snomed.info/id
/254294008)

19 Substance Active chemical constituents of allergens, 116272000 | Dietary

agents, substances, chemicals, drugs, and fiber (substance) | (
materials (not Pharmaceutical/Biological http://snomed.info/id
Products) /116272000)

64856004 | Digestive
system fluid
(substance) | (
http://snomed.info/id
/64856004)

Granularity
The scale, or level of detail, in a terminology is called granularity. Concepts and meanings range from very general,
or coarse, to very specific, or fine. SNOMED CT has multiple granularities, which is an important component of
terminologies that are multi-purpose. The broader meanings are useful for aggregation (e.g. Clinical Finding,
Procedure, etc.), but are not intended for recording individual patient data.
The progressive levels of refinement are used to meet clinical data requirements. There are, however, limits to the
degree of precoordination of certain types of complex statements.
In general, concepts in SNOMED CT should name things that exist in the real world. The concepts are usually names
or short noun phrases, not complete sentences or paragraphs.

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SNOMED CT is intended to be used with electronic health applications that can support full clinical statements,
along with their attributions, dates, times, and statement interrelationships. It may be challenging to balance
SNOMED CT content with the needs of those using electronic health applications. For example, some older
applications may require concepts outside of the scope of SNOMED CT. SNOMED CT tries to maximize its
usefulness and at the same time minimize precoordination.

Knowledge Representation
Knowledge representation in SNOMED CT involves modeling what we know about concepts to be necessarily true.
Concepts are logically defined by their relationships to each other. Some knowledge provides valuable clues to the
diagnostician, while not necessarily always present, i.e. it is uncertain or probabilistic knowledge.
For example,
22298006 | Myocardial infarction (disorder) | (http://snomed.info/id/22298006)
Its terminological knowledge includes the following:
IS A: 64572001 | Disease (disorder) | (http://snomed.info/id/64572001)
Finding site: 74281007 | Myocardium structure (body structure) | (http://snomed.info/id/74281007)
Associated morphology: 55641003 | Infarct (morphologic abnormality) | (http://snomed.info/id/55641003)
These additional pieces of knowledge are variably present and therefore represent uncertain or probabilistic
knowledge about myocardial infarction:
Crushing substernal chest pain
Diaphoresis
Arrhythmia
ST-segment elevation on EKG
Elevated cardiac enzymes
For example,
74400008 | Appendicitis (disorder) | (http://snomed.info/id/74400008)
Its terminological knowledge includes the following:
IS A: 64572001 | Disease (disorder) | (http://snomed.info/id/64572001)
Finding site: 66754008 | Appendix structure (body structure) | (http://snomed.info/id/66754008)
Associated morphology: 23583003 | Inflammation (morphologic abnormality) | (http://snomed.info/id/23583003)
These additional pieces of knowledge are variably present and therefore represent uncertain or probabilistic
knowledge about appendicitis:
Central abdominal pain that migrates to the right lower quadrant
Rebound tenderness over McBurneys point
Anorexia
Nausea
Elevated white blood count

Semantic Interoperability

Semantic Interoperability
The overall semantic interoperability of electronic health applications is achieved through the combined
functioning of the information architecture of the application and the terminology that populates it. A basic
principle of SNOMED CT is to create and maintain semantic interoperability of clinical information. Semantic
interoperability is the capability of two or more systems to communicate and exchange information. Each system
should be able to interpret the meaning of, and effectively use, received information. To achieve this goal, the
meaning of the information must be agreed upon, consistent, and clearly expressed.

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URU - Understandable, Reproducible, Useful

There are three basic operational criteria that help determine SNOMED CT's ability to create and sustain semantic
interoperability. The content must be:
Understandable. Healthcare providers must be able to communicate the meaning of concepts such that they
are unambiguous and understood by recipients without reference to inaccessible, hidden or private
meanings. Concepts should be universally understood.
Reproducible. It is not enough for one individual to say they think they understand a meaning. It must be
shown that multiple people understand and use the meaning in the same way.
Useful. The meaning must have some demonstrable use or applicability to health or healthcare.

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Concept Model Overview

The Concept Model is used to specify logical definitions of SNOMED CT concepts. It is based on a combination of
formal logic and editorial rules. It includes the attributes and values that may be applied to the concepts.

Definition Note

The set of rules that determines the The Concept Model specifies the attributes that can be applied to
permitted sets of relationships between concepts in particular domains and the ranges of permitted values
particular types of concepts for each of these attributes. There are also additional rules on the
cardinality and grouping of particular types of relationships

Root and Top-level Concepts

Concept
A concept is defined as a clinical idea to which a unique concept identifier has been assigned. Concepts are
associated with descriptions that contain human-readable terms describing the concept.

Term
A term is defined as a human-readable phrase that names or describes a concept. A term is one of the
properties of a description. Other properties of a description link the term to an identified concept and
indicate the type of description, e.g. Fully Specified Name, Preferred Term, Synonym.

Concepts are linked to their more general parent concepts directly above them in a hierarchy. More general
meanings, are usually at the top of the hierarchy. Descending levels of the hierarchy contain more specific or
specialized meanings.
Concepts are logically defined by their relationships to each other.
In SNOMED CT, the default meaning of a concept is defined above. However, a concept may have other meanings
in SNOMED CT, such as an:
Abbreviated name for the concept identifier. For clarity, this is should be referred to as an identifier (ID), or
code, e.g. concept identifier (ID) or concept code.
Idea or class of real-world entities (common usage meaning). For clarity, this is should be referred to as an
idea or meaning, e.g. a clinical idea, clinical meaning, or code meaning.

Root Concept
The concept file includes a special concept referred to as the root concept. It is the single concept that is at the top
of the SNOMED CT concept hierarchy. All other concepts are descended from this root concept via at least one
series of relationships of the Relationship type 116680003 | Is a (attribute) | (http://snomed.info/id/116680003), i.e. all
other concepts are regarded as subclasses of this concept. The root concept code is 138875005 | SNOMED CT
Concept (SNOMED RT+CTV3) | (http://snomed.info/id/138875005), with the preferred term (PT), SNOMED CT Concept.

Features of the root concept

All other SNOMED CT concepts are subtypes of the root concept. Unlike other SNOMED CT concepts, the root
concept is not a subtype of any other concept.

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Top-level Concept
Concepts that are directly related to the root concept by a single relationship of the Relationship type 116680003 | Is
a (attribute) | (http://snomed.info/id/116680003) are referred to as top-level concepts. All other concepts are descended
from at least one top-level concept via at least one series of relationships of the Relationship type 116680003 | Is a
(attribute) | (http://snomed.info/id/116680003), i.e. all other concepts represent subclasses of the meaning of at least
one top-level concept.
Top- level metadata concepts
A concept that is directly related to the root metadata concept, 900000000000441003 | SNOMED CT Model
Component (metadata) | (http://snomed.info/id/900000000000441003) by a single relationship of the relationship type
IS_A. All metadata concepts are descended from at least one Top-Level Metadata concept via at least one series of
relationships with Relationship type IS_A. Metadata codes represent structural information about the terminology
itself. The top-level metadata concepts represent broad groups of metadata.

Subtype Relationships

Role of subtype relationships

Subtype relationships provide the main semantic hierarchy that relates concepts to one another. All active concepts,
except the root concept, have subtype relationships with one or more concept. Each of these relationships indicate
that a concept is a subtype of another concept.

Representation of subtype relationships

Subtype relationships are expressed in the same way as other SNOMED CT relationships. They are identifiable by
their fully specified names, e.g 116680003 | Is a (attribute) | (http://snomed.info/id/116680003).
For example ,

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53084003 | Bacterial pneumonia (disorder) | (http://snomed.info/id/53084003) is a subtype of 233604007 |

Pneumonia (disorder) | (http://snomed.info/id/233604007) because it is a subtype of 312342009 | Infective
pneumonia (disorder) | (http://snomed.info/id/312342009) which is also a subtype of 233604007 | Pneumonia
(disorder) | (http://snomed.info/id/233604007)

Attributes

Attribute

Definition Notes Example

Represents a characteristic An attribute has a name which is represented by a 116676008 | Associated

of the meaning of a concept. All of the concepts that can be used to morphology (attribute)
concept or the nature of a name attributes are subtypes of the concept | (http://snomed.info/id
refinement 410662002 | Concept model attribute (attribute) | ( /116676008)
http://snomed.info/id/410662002).

An attribute is assigned a value (that creates an

attribute-value pair) when used in the definition of
a concept or in a postcoordinated expression.
The permitted range of values for an attribute
depends on the rules specified in the concept
model.

Range

Definition Note Example

A constrained set of values The range of permitted values that can be The range fo r values of
that the Concept Model applied to an attribute is typically defined to 116676008 | Associated
permits to be applied to a include concepts in one or more branches of the morphology (attribute)
specific attribute when that subtype hierarchy. | (http://snomed.info/id
attribute is applied to a /116676008) is a subtype
concept in a particular of 49755003 |
domain Morphologically
abnormal structure
(morphologic
abnormality) | (
http://snomed.info/id
/49755003).

Not all hierarchies in SNOMED CT have defining attributes. Many attributes apply to top-level domain hierarchies,
some to more than one. Some attributes to a lower-level, or a more specific, domain hierarchy. Primitive concepts
in some hierarchies may be attribute values in top-level hierarchies.

Attribute naming
Attributes should be named as verb senses, so that object-attribute-value relationships may actually be read. For
example, a name of "Has filling (attribute)" is preferred over "Filling (attribute)" and "Has property (attribute)" is
preferred over "Property (attribute)." Then a concept such as 464376000 |Saline-filled breast implant (physical object)
| could be defined with the attribute "Has filling (attribute)" and a value of 387390002 |Sodium chloride (substance)|.

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Attribute hierarchy
Selected SNOMED CT attributes have a hierarchical relationship to one another known as attribute hierarchies. In an
attribute hierarchy, one general attribute is the parent of one or more specific subtypes of that attribute. Concepts
defined using the more general attribute can inherit concepts modeled with the more specific subtypes of that
attribute providing the attribute value is the same or a subtype of the attribute value used for the concept that is
defined with the more general attribute .
Clinical finding and Event attribute hierarchies
Associated with
Causative agent
Due to
Temporally related to
After
Before
During
Procedure attribute hierarchies
Procedure Site
Procedure site - Direct
Procedure site - Indirect
Procedure device
Direct device
Indirect device
Using device
Using access device
Procedure morphology
Direct morphology
Indirect morphology
Body structure attribute hierarchy
All or part of
Proper part of
Constitutional part of
Regional part of
Lateral half of
Systemic part of
Medicinal product attribute hierarchy
Has ingredient (not used in the international edition)
Has active ingredient
Has precise active ingredient

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Defining Characteristics

Role of defining characteristics

Defining characteristics represent the values of a range of relevant attributes. Depending on the nature of the
concept, they may include etiology, topography, method, etc.
The attributes that can be applied depend on the domain of the concept. For example, a procedure may have a
method, and a disorder may have an etiology, but a procedure cannot have an etiology, and disorder cannot have a
method. Defining characteristics using a particular attribute will be applied consistently to all concepts to which it is
relevant. Note that this design principle may not be fully realized for all attributes in each release.

Representation of defining characteristics

Defining characteristics are represented as relationships. The fields are used as follows:
SourceId refers to the concept to which a defining characteristic applies;
TypeId indicates the nature of the defining attribute;
DestinationId refers to the concept that represents the value of that attribute.

Relationships
The defining characteristics can be divided into 116680003 | Is a (attribute) | (http://snomed.info/id/116680003)
relationships and defining attribute relationships.
The IS_A relationship (also called supertype-subtype or parent-child relationship) builds the hierarchies in SNOMED
CT. Every concept has at least one IS_A relationship to a supertype or parent concept.

Exception
138875005 | SNOMED CT Concept (SNOMED RT+CTV3) | (http://snomed.info/id/138875005) has no
supertype or parent relationship.

Each concept in SNOMED CT is logically defined through its relationships to other concepts. A relationship is
defined as an association between a source concept and a destination concept. The type of association is indicated
by an attribute concept. It is the relationships that make up the defining characteristics of the concepts. A defining
characteristic is a relationship to a target concept that is always necessarily true for any instance of the source
concept.
For example, the defining relationships of the concept 53442002 | Gastrectomy (procedure) | include:
116680003 | Is a (attribute) | (http://snomed.info/id/116680003) = 65801008 | Excision (procedure) | (http://snomed.
info/id/65801008)

260686004 | Method (attribute) | (http://snomed.info/id/260686004) = 129304002 | Excision - action (qualifier

value) | (http://snomed.info/id/129304002)
405813007 | Procedure site - Direct (attribute) | (http://snomed.info/id/405813007) = 69695003 | Stomach
structure (body structure) | (http://snomed.info/id/69695003)

Qualifying Characteristics
A qualifying characteristic is expressed by an attribute-value pair. The attribute may have one value, from a range of
values, based on the domain's Concept Model. If a particular qualifying characteristic is applied to a concept, the
resulting expression represents a more tightly defined subtype of that concept.

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Clinical expressions using SNOMED CT concepts can be of two types: precoordinated expressions, which
use a single SNOMED CT concept identifier; and postcoordinated expressions, which contain more than
one SNOMED CT concept identifier.

For example,
It might be possible to qualify a disorder such as 53084003 | Bacterial pneumonia (disorder) | (http://snomed.
info/id/53084003) according to its clinical course ( 373933003 | Acute onset (qualifier value) | (http://snomed.info
/id/373933003) or 90734009 | Chronic (qualifier value) | (http://snomed.info/id/90734009)) or severity ( 255604002
| Mild (qualifier value) | (http://snomed.info/id/255604002), 6736007 | Moderate (severity modifier) (qualifier value)
| (http://snomed.info/id/6736007), or 24484000 | Severe (severity modifier) (qualifier value) | (http://snomed.info/id
/24484000))

125605004 | Fracture of bone (disorder) | (http://snomed.info/id/125605004) can be refined by qualifying it with

12611008 | Bone structure of tibia (body structure) | (http://snomed.info/id/12611008) to represent the concept
31978002 | Fracture of tibia (disorder) | (http://snomed.info/id/31978002)

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Authoring

Modeling philosophy of SNOMED CT

SNOMED CT authors use a zero-based, proximal primitive approach when modeling or editing logical definitions of
concepts, i.e. a concept is newly defined, as opposed to inheriting the definition from the parent and then refining it.
This is accomplished by assigning the immediate proximal primitive parent and attribute relationships based on
their relevance to the defining characteristics of the concept, again, instead of relying on inheritance and refinement
of relevant attributes from immediate, sufficiently defined supertypes.
The steps are as follows:

1. The author states the proximal primitive supertype/s.

2. The author states all of the defining attribute-value pairs required to express the meaning of the concept.
a. An attribute-value pair is explicitly stated, even if it is already present on a supertype concept.
b. The attribute-value pairs are grouped as required.
3. The classifier infers all appropriate proximal supertype/s.
a. With sufficiently defined concepts, the subtypes are also inferred.

Advantages of the approach

Enhances ability to maintain content
Supports identification of equivalences

Content that does not conform

SNOMED CT contains content that does not conform to the current modeling patterns. A project to correct these
non-conforming concepts is currently underway.

Exceptions
Exceptions exist where the current concept model is not expressive enough to represent critical defining
characteristics of a concept that would allow for its sufficient definition.
For example, disorders where the clinical manifestations are variably present (i.e. genetic diseases)

Authoring information

Does It Belong In SNOMED CT?

The guiding principle underlying the creation of a clinical reference terminology is the facilitation of semantic
interoperability. To this end, content in SNOMED CT must represent unambiguous, clinically relevant information
which can be exchanged and understood internationally. A reproducible and consistent approach to incorporating
terminology into electronic health applications is, therefore, mandatory.
The International Release includes content necessary for international conformance and interoperability (The
International Release was formerly and is colloquially known as the core). The range of concepts, attributes,
qualifiers, and other components of SNOMED CT is comprehensive compared to classification systems. This
supports the terminological needs of those using SNOMED CT with electronic health applications.

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Addition of new content to SNOMED CT requires careful consideration. Changes and additions to the International
Release of SNOMED CT follow a formal process executed by the SNOMED CT authors.

Extensions
Extensions are created, structured, maintained, and distributed in accordance with SNOMED CT
specifications and guidelines to ensure compatibility with the SNOMED CT International Release.
Members may create, maintain, and distribute extensions to address specific national, regional, and
language requirements. Affiliates may also create, maintain, and distribute extensions to meet the needs
of particular software solutions and customers. Please see the Practical Guide to Extensions for more
information.

Criteria for inclusion in the International Release

For content to be included in the International Release, the following criteria must be met:

Usefulness
Content submitted for inclusion in the International Release shall be required to pass a test for "usefulness." The
usefulness test can be passed in more than one way. At least one of the following must be satisfied:

1. Content that is used by more than one major user (a National Release Center such as NHS, a vendor/supplier
of Clinical Information Systems with international scope, or a large intra-national system user such as VA or
Kaiser) will be considered to have passed the "usefulness" criterion.
2. Data demonstrating significant frequency of use, or frequency of need, by a single user (single national
center, or single vendor, or single health care system) can also be used as evidence in support of
"usefulness".

Additional means of passing the usefulness test may be added in the future. Submissions that pass the usefulness
criterion must also pass understandability and reproducibility tests, and conform to style rules.

Broad Use
It must be applicable within and across healthcare disciplines internationally.

Provision of Use Case

Changes and additions must follow SNOMED CT Content Request Service (CRS) Guidelines. It is very important to
incorporate a clear justification for any change or addition request for the International Edition of SNOMED CT.

Principle of URU
Understandable. The terminology must be able to communicate to recipients the intended meaning of the
healthcare provider in terms that are unambiguous and comprehensible without reference to inaccessible, hidden,
or private meanings.
Reproducible. Concepts should be names that are human-understandable representations of the codes. It is not
enough for an individual to say they think they understand a meaning. It must be shown that multiple people
interpret and use the meaning in the same way.
Useful. The meaning must have demonstrable use or applicability to health or healthcare.

SNOMED CT names classes of things

SNOMED CT concepts should name classes of things. Concepts that refer to a particular instance are unacceptable.
For example, Doctor Jones pre-operative order set should not be included because it is an individual instance, not a
class.

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References
Content must be submitted with:
Definitions and literature references. All reference material must be publicly available. Wiki references are
unacceptable.
Evidence of international applicability. Without international applicability, a concept should, instead, be added
to the submitter's extension.

Change Requests
For details on SNOMED International CRS Customer Guidance, search for Change or Add to SNOMED CT
in the document library at http://snomed.org/doc.

(See also Appendix: Principles for Accepting Content in the International Release)

When Is Content Rejected?

The following information provides specifics on content rejection.

Fully specified name (FSN)

An FSN should conform to spelling, language, and style guidelines. It should also have parent codes that conform to
editorial guidelines and show where in the hierarchy it belongs.
In general, an FSN should not have the following (there are exceptions, which are covered in this guide):
Abbreviations or acronyms
Hyphens
Duplicate concepts
Ambiguity
The word OR
Forward or backslash (/ \)
Precoordinated numeric ranges
General British (GB) spelling
Plural form
Procedures or clinical findings in past tense
Reference to a particular instance

Classification system-derived phrases

Concept submissions that contain certain classification system-derived phrases in their FSNs are not accepted.
Concepts with unclear, unspecified, or ambiguous meaning should not be used. It includes:
Not otherwise specified (NOS)
For example, Mental disorder, not otherwise specified
Not elsewhere classified (NEC)
For example, Chronic hepatitis, not elsewhere classified
Not mentioned
For example, Attention deficit disorder not mentioned of hyperactivity
With or without
For example, Tubal pregnancy with or without intrauterine pregnancy

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Full statements or sentences

Concepts should be names or short noun phrases. Full statement or sentences are unacceptable.

Disjunctives
Concepts with the disjunctives (or, and/or) are unacceptable with limited exceptions as follows below; Instead, there
should be separate concepts.

Exceptions
Disjunctives may be used if the:
The referent is a single thing, but there isn't a name for it.
For example,
774007 | Structure of head and/or neck (body structure) | (http://snomed.info/id/774007)
The concept is an intensional navigational aggregate.
For example,
707861009 | Structure of skin and/or skin-associated mucous membrane (body structure) | (
http://snomed.info/id/707861009)

The concept is based on an authoritative source, but not a classification system.

See Conjunction and Disjunction for the use of disjunctives, including their use with anatomical
concepts.

Numeric ranges
In general, content that depends on numeric ranges should not be used for precoordination.
For example,
There may be too many possibilities
A finding of number of lesions might have ranges of 1, 2 to 5, and greater than 5; 1 to 2, 3 to 10, and
greater than 10, or etc.
There may be possible changes to reference ranges or systems of units
The normal serum sodium concentration is usually defined as 135 to 145 mEq/L. Low serum sodium
should not use the phrase serum sodium less than 135 mEq/L. (It should use a phrase such as serum
sodium concentration below reference range)
A body mass index (BMI) score as an indicator of obesity

Exception: acceptable numeric range

A standard definition with a fixed numeric range, i.e. the range is an explanation or definition of the score,
may be acceptable.
For example,
A histologic scoring system with a score of 1 when there are 0 to 5 mitoses per high power field,
and a score of 2 when there are 6 to 10, and etc
The Tumor, Node, Metastases (TNM) Classification of Malignant Tumor

Proprietary names
Proprietary names include brand name drugs and devices and some clinical forms or tools.

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Brand name of drugs and devices. Proprietary names are the names that have been assigned to products, usually
drugs and devices, by their corporate producers. They do not require a license from the producer.
It is both necessary and useful to include proprietary names in a health terminology. However, they should not be
included in the International Release, but instead in National Extensions. This is because proprietary names may
refer to different products depending on the country and the meaning of these names are dependent on the
country or jurisdiction in which the product is approved.

Modeling
A brand or trade name may stand for a category of product and not the particular brand itself. These
proprietary names may be included in the International Release as descriptions (non-FSN descriptions).
They should not be included in FSNs.
For example,
Kleenex, band aid, popsicle

Regulatory status or characterization

Concepts referring to regulatory status or characterization (e.g., over-the-counter) are out of scope for the
International Release. Meaning may vary by jurisdiction and may not be consistent internationally.
Clinical forms, tools, or assessment scales. The owner of a form or tool may be an individual or organization that
created it; the healthcare organization that employed the individual; or it may be a commercial organization to
which the rights were assigned.
Names of clinical forms, tools, or assessment scales (e.g. the XYZ Test) do not require a license from the owner.
Questions. Questions within a form or tool generally qualify for copyright protection (except in the case of the
simplest of forms).
Answers. Very simple answers on a form or tool (e.g. yes or no) do not require owner permission. However, more
substantial answers may infringe on the owner's copyright. This usually does not apply to individual answers, but
almost always to entire sets of answers.
Scores. The principles that apply to individual answers also apply to the overall score generated by a clinical form or
tool. The incorporation of numbers does not infringe on the copyright. However, when each possible score has an
associated textual description and all possible scores and descriptions are incorporated into SNOMED CT, a license
is required.
For example,
443807003 | EuroQoL five dimension questionnaire (assessment scale) | (http://snomed.info/id/443807003) is a
SNOMED CT concept. However, these scores are subject to copyright protection, therefore cannot be added
to SNOMED CT:
EuroQol Five Dimension (youth) doing usual activities score
EuroQol Five Dimension (youth) feeling worried, sad or unhappy score

Non-human content
To be included in the International Release content must be useful in human medicine. Strictly non-human content
may be included in extensions. Criteria for non-human content to be included in the International Release include
the following:
Diseases, Findings, and Procedures. Occurs in both humans and animals.
Substances. Causes poisonings and adverse effects in humans.
Organisms. All organisms are included in the International Release.

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Procedures: by complexity or count

Procedures categorized by complexity. Procedure concepts with modifiers representing complexity are not allowed
in the International Release; this means the amount of effort required or based on realm-specific definitions (e.g.
simple arthrodesis, simple repair, complex repair).

Exception
Procedures that use simple or complex, defined with reproducible meanings are allowed; they are based
on what is done to or for the patient, rather than how much effort is expended.
For example,
172043006 | Simple mastectomy (procedure) | (http://snomed.info/id/172043006); Reproducibly
defined as the removal of all breast tissue without removal of axillary contents. Differentiated from
modified radical, radical, skin-sparing, and subcutaneous variants of mastectomy.

Counts of the number of procedures. Many procedure classifications focus on resources required to complete; this
may be for reimbursement or tracking purposes (e.g. placement of one stent versus placement of two stents). This
information should be part of patient documentation and is not allowed in the International Release.
Order of procedures. The order of procedures, e.g. primary or first, second, and etc. should be excluded.

Abbreviations
Abbreviations are shortened forms of words or phrases. Because they may not be understood by all users, they
allow for misinterpretation. Consequently they are not permitted in FSNs. They may be used in preferred terms or
synonyms if they are accompanied by the fully expanded term.

Acronyms
Acronyms are a specific type of abbreviation. They are formed from the initial letters of words and pronounced as
words.

Exception
An acronym is allowed when it has become a word in its own right, i.e. included in dictionaries;
understood without expansion to its original full form.
For example,
122456005 | Laser device (physical object) | (http://snomed.info/id/122456005)

Eponyms
Eponyms are names that are derived from proper names (usually the person who made the discovery or created the
original description). They are found in many areas of health terminology, including anatomic structures,
morphologic abnormalities, diseases, findings, and procedures.
For example,
Rutherford Morrison's pouch, vein of Galen, Aschoff body, Kell blood group, Down syndrome, Moro reflex,
and Whipple procedure.
It is neither desirable nor possible to completely avoid using eponyms in a health terminology; although, if possible,
they should be avoided. This helps to improve clarity of meaning and to facilitate translation to other languages.
FSNs should be full descriptions, whereas synonyms may be eponymous terms.
For example,
Infant startle reflex would be the FSN and Moro reflex would be the synonym.

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It is permitted and encouraged to include eponyms as descriptions (non-FSN terms) whenever they are
understandable, reproducible, and useful in a given context.

Exceptions
Exceptions require careful consideration since eponym meanings may change over time. Reasons for
exceptions are:
The full description is exceptionally long and unwieldy.
For example,
233230003 | Hemi-Fontan operation (procedure) | (http://snomed.info/id/233230003) instead of
bidirectional Glenn shunt with end-to-side anastomosis of proximal superior vena cava to
right pulmonary artery with isolation from right atrium. (However, this should be added as a
text definition).
The eponym is the only precise, clinically relevant name available.
A non-eponymous name would necessarily be vague or subject to misinterpretation.
For example,
118599009 | Hodgkin's disease (disorder) | (http://snomed.info/id/118599009) and 118617000 | Burkitt's
lymphoma (disorder) | (http://snomed.info/id/118617000) are both clear.

Hyphens

Hyphens
Hyphens should not be used in FSNs, with rare exceptions.
For example,
In the morphology hierarchy, where categories need to be distinguished from specific subtypes; 416500007 |
Malignant glioma - category (morphologic abnormality) | (http://snomed.info/id/416500007) is allowed to
differentiate it from a specific morphology of 74532006 | Glioma, malignant (morphologic abnormality) | (
http://snomed.info/id/74532006) as defined by ICD-O.

Adjudication for Content Requests

There are processes for making decisions about adding or changing content in SNOMED CT.

Change requests
All change requests, whether for new content or for change to existing content, go through a request submission
approval process. It involves review by authors to determine that there is:
International applicability
Compliance with Understandable, Reproducible, Useful (URU) principles
No duplication with existing content
No link to existing larger projects, as detailed in a Content Tracker document
No conflict with existing collaboration agreements (e.g. Logical Observation Identifiers Names and Codes
(LOINC) agreement)

Legacy concepts
Legacy concepts, i.e. concepts not in the current draft/work-in-progress version of SNOMED CT, may not
follow current guidelines. Requests based on legacy concepts are unacceptable.

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Appeals, deferrals, and resolution

Appeals. Requests that are rejected may be appealed by the submitter.
Deferrals. Requests may be deferred for a number of reasons including questions about:
How to model the concept; which attributes may be used
Concept meaning
Literature reference missing or inadequate
Use Case unclear
Size of required change (attached to a Content Tracker)
Resolution. Resolution of deferrals may result in a decision delay requiring:
A larger project or work item or
Referral, internally, to other groups for decision. This depends on the complexity of the request and
understanding of the wider impact.

Results
Results of adjudication are received by email from the Content Request System (CRS). Simpler issues can be
resolved expeditiously (e.g. by a ruling from the Head of Terminology).

Descriptions

Descriptions
A concept has multiple associated descriptions.
Each description has a description type and a unique numeric description identifier.
Fully specified name (FSN) and synonym (SYN) are description types in SNOMED CT.
A preferred term (PT) is a synonym that has been marked as preferred.
Every concept has one preferred term, unless there is variant spelling between U.S. and GB English. If so, there
are two preferred terms.
For example,

22490002 | Bleeding from mouth (disorder) | (http://snomed.info/id/22490002)

Description type Description

FSN Bleeding from mouth (disorder)

PT Bleeding from mouth

SYN Bleeding in mouth

SYN Bleeding of mouth

SYN Oral hemorrhage

SYN Oral haemorrhage

SYN Stomatorrhagia

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22490002 | Bleeding from mouth (disorder) | (http://snomed.info/id/22490002)

241563001 | Computed tomography of upper limb (procedure) | (http://snomed.info/id/241563001)

Description type Description

FSN Computed tomography of upper limb (procedure)

PT CT of upper limb

SYN Computed tomography of upper limb

Fully Specified Name

Fully specified name (FSN) definition

A term unique among active descriptions in SNOMED CT that names the meaning of a concept code in a manner
that is intended to be unambiguous and stable across multiple contexts.

Precoordinated patterns
For information on acceptable precoordinated naming patterns, see The Pre-coordination Pattern JIRA
Project. New content should conform with the naming patterns, however legacy content may not.

An FSN is one type of description, unique among active descriptions in SNOMED CT. It provides the meaning of a
concept so that it is unambiguous, stable across multiple contexts, and optimally understandable to those whose
first language is not English. Consequently, it is not always clinician-friendly or in common use.
In the majority of cases, where the FSN is clinician-friendly and in common use, a description matching the FSN
should be added to the concept. This description is not required to be the preferred term (PT). In certain instances,
where the FSN does not provide a clinically useful description, a matching description without the semantic tag is
unnecessary.
For example,
FSN: Repair of common bile duct (procedure) - the meaning
PT: Choledochoplasty - commonly understood clinical name
Choledochoplasty is marked as preferred in the US English Language Reference Set; choledochoplasty is the
preferred term for this concept in US English.
Each new content request should have an FSN that conforms to spelling, language, and style guidelines. It should
also have SNOMED CT parent concepts that conform to editorial guidelines and show where in the hierarchy it
belongs. In the Content Request System (CRS), if the meaning of the FSN is unclear or the parent codes are not
provided, authors should request the information from the submitter.
A well formed FSN includes:
Correct US spelling, not GB (General British) spelling
Singular form, not plural form
Procedures in present tense, not past tense
A semantic tag in parentheses at the end
An FSN with an approved disjunctive (although not often used), e.g. Traumatic and/or non-traumatic injury of back
(disorder), should have lower case and/or.

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An FSN should not have:

Abbreviations or acronyms
Hyphens
Duplicate concepts
Ambiguity
The word OR (not including the disjunctive and/or)
Forward or backslash (/ \)
Precoordinated numeric ranges
Reference to a particular instance
Reason or indication for a procedure, unless this directly impacts the method

Exceptions that should not be amended include:

Trademark names
Latin names of organism
Scientific names

Structure, Structure of
When constructing the FSN for a disorder, finding, or procedure containing a body structure, the wording
of the body structure should follow the naming convention of the body structure concept. However, it
should not include the words structure or structure of.
For example,
For the body structure concept, 266005 | Structure of lower lobe of right lung (body structure) | (
http://snomed.info/id/266005), a procedure with this body structure is 726425007 | Lobectomy of
lower lobe of right lung (procedure) | (http://snomed.info/id/726425007).
For the body structure concept, 74386004 | Nasal bone structure (body structure) | (http://snomed.
info/id/74386004), a disorder concept with this body structure is 413878002 | Closed, displaced
fracture of nasal bone (disorder) | (http://snomed.info/id/413878002).

Unique
The FSN is unique among active concepts. Creating a synonym to match the FSN is no longer mandatory because
the SNOMED International Authoring Platform automatically creates a matching description to the FSN. Authors
then determine the clinical usefulness of the matching description. Those that are useful are maintained in SNOMED
CT; those that are not useful are removed. The Authoring Platform displays a warning when the matching
description is removed; this does not prevent the author from saving the concept.
The FSN should provide a linguistic representation of the concept in an unambiguous way. It is considered an
anchor for the representation of meaning of a concept, to which modelers can refer, when assigning a logic-based
definition. The FSN does not necessarily follow the usual phrasing used in clinical practice; it may be phrased
differently and may be longer and more fully spelled out in order to represent the meaning as clearly as possible
and globally communicate the intended meaning of the concept.

Unambiguous
A single term may have more than one meaning. Therefore, FSNs should be checked for ambiguity.
For example, immunosuppression may mean the state of being immunosuppressed, or it may mean the application
procedure of immunosuppressive therapy.
The following FSNs are clear and acceptable.

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For example,
Benign neoplasm of clavicle (disorder)
Excision of cyst of spleen (procedure)
The following FSNs are ambiguous and should be inactivated.
For example,
Standing in water side toward (finding); does not indicate which side of what is toward what
Lumbar ache - renal (finding); does not convey whether the lumbar ache is specifically a renal etiology or is
merely located in the renal area

Minor Changes - only the FSN changes but not the concept
Minor changes, those changes that do not change the meaning of the FSN, are allowed without inactivation of the
concept. They may include:
Capitalizing, i.e. from lower to upper case or upper to lower case
Changing punctuation
Changing spelling
Replacing an acronym with its expansion (only if it is commonly understood and not ambiguous)
Expanding an abbreviation
Correcting word order without changing the meaning (only for an error)
Correcting typos
Removing articles, such as 'the', from concept string
Aligning with editorial policy, e.g. changing appendectomy to excision of appendix
Where a change to the FSN does not result in a change to the preferred term
Some FSN changes are necessary for style consistency; again, changes are only acceptable if the meaning does not
change. They may include changing:
Semantic tag type within a single top-level hierarchy
For example,
A finding tag to a disorder tag
A procedure tag to a regime/therapy tag
A substance or product name to reflect the International Nonproprietary Name (INN)
The current scientific name of an organism ( only applies to 410607006 |Organism (organism)| hierarchy )

Modeling tips
When making a minor change to an FSN, a new description must be created and the old description
must be inactivated. While the description ID will change, the concept ID remains the same.
Below is the order of actions in the SNOMED CT Authoring Platform when the FSN requires a minor
change:

1. Add the new description, setting case significance

2. Change the new description type to FSN
3. DO NOT SAVE YET
4. Inactivate old FSN description
5. Now save

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Major Changes - When to inactivate the concept

Major changes to FSNs require inactivation of the concept. The following are examples of major changes, when:
Changing the FSN changes the meaning
The FSN is ambiguous
Modeling is more specific than the FSN meaning
The FSN meaning is more specific than the modeling; inactivation is determined case-by-case as this could
simply be a primitive concept which cannot be defined
Moving to a different top-level hierarchy
Changing the common name to the scientific name
Ancestors and descendants (if any) of the concept are inconsistent with what is implied by the FSN -
inactivate concepts

International FSNs
The FSN for a concept in the International Release is designated an International FSN. The International FSN is
considered the gold standard for interpretation of the meaning of the concept, from a linguistic standpoint.
The logical definitions, represented using the concept model, should represent the same meaning. Spelling of the
International FSN follows United States (American) English spelling conventions. Other English language spelling
and conventions, such as Great Britain (GB) English, may be represented in preferred terms and other descriptions.
They should be appropriately tagged using the Language Reference Set mechanism.
For example,
191268006 | Chronic anemia (disorder) | (http://snomed.info/id/191268006)
FSN: Chronic anemia (disorder)
US PT: Chronic anemia
GB PT: Chronic anaemia
414545008 | Ischemic heart disease (disorder) | (http://snomed.info/id/414545008)
FSN: Ischemic heart disease (disorder)
US PT: Ischemic heart disease
GB PT: Ischaemic heart disease

Acronyms
Acronyms are easily misinterpreted. For this reason, all acronyms are unacceptable in FSNs.
For example, the FSN should be the expanded form, Computed tomography of chest (procedure), however as a
preferred term, CT of chest (procedure) is acceptable.
If there is an acronym in an existing FSN, the FSN DescriptionId is inactivated and a new FSN is created (regardless
of whether or not the acronym was in parentheses with the expanded form). The replacement FSN concept has the
expanded description with the acronym entirely removed. Inactivating the ConceptId is not necessarily required,
unless the FSN had significant ambiguity before changing it to its expanded form.

Imported FSNs
Before any changes are made to an FSN, imported directly with an extension (local) ID, the submitter should be
notified and confirmation sought that no loss of meaning has occurred. This helps to ensure that the original
meaning is understood and maintained. Authors should:
Adhere to naming conventions.
Advise the submitter of changes and confirm that they are acceptable.
Check for existing concepts with the same FSN; the term may be added as a preferred term or synonym.

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Original submitter
Changes to existing SNOMED CT concepts do not necessitate notifying the original submitter.

Semantic Tags
Semantic tags are part of FSN descriptions. They are placed in parentheses at the end of FSNs when authoring
concepts. They indicate the domain to which a concept belongs. For example, body structure, disorder, or
specimen.
The purpose of semantic tags is to disambiguate concepts which have the same commonly used word or phrase.
For example,
Hematoma (morphologic abnormality)
Hematoma (disorder)
The following table contains the semantic tags for each domain.

Domain Semantic tags

Body structure (body structure) (body structure)

(cell)
(cell structure)
(morphologic abnormality)

Clinical finding (finding) (finding)

(disorder)

Environment or geographical location (environment / (environment)

location)
(geographic location)

Event (event) (event)

Observable entity (observable entity) (observable entity)

Organism (organism) (organism)

Pharmaceutical / biologic product (product) (clinical drug)

(medicinal product)
(medicinal product form)
(physical object)
(product)

Physical force (physical force) (physical force)

Physical object (physical object) (physical object)

(product)

Procedure (procedure) (procedure)

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(regime/therapy)

Qualifier value (qualifier value) (qualifier value)

(administration method)
(basic dose form)
(disposition)
(dose form)
(intended site)
(number)
(product name)
(release characteristic)
(role)
(state of matter)
(transformation)
(supplier)
(unit of presentation)

Record artifact (record artifact) (record artifact)

Situation with explicit context (situation) (situation)

SNOMED CT Model Component (metadata) (attribute)

(core metadata concept)
(foundation metadata concept)
(link assertion)
(linkage concept)
(namespace concept)
(OWL metadata concept)

Social context (social concept) (social concept)

(ethnic group)
(life style)
(occupation)
(person)
(racial group)
(religion/philosophy)

Special concept (special concept) (inactive concept)

(navigational concept)

Specimen (specimen) (specimen)

Staging and scales (staging scales) (staging scale)

(assessment scale)

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(tumor staging)

Substance (substance) (substance)

Preferred Term
A preferred term (PT) is the description that is deemed to be the most clinically appropriate way of expressing a
concept in a clinical record. It represents a common word or phrase used by clinicians to name a concept in clinical
practice or in the literature. It is the synonym that is preferred in a language or dialect.
The use of a description can vary between different languages, dialects and contexts. A description may be
preferred in some dialects, acceptable in others, and may not be used in some dialects. A Language Reference Set is
used to specify the descriptions that are preferred or acceptable in each language or dialect.
A concept may have two descriptions marked as PT, one for each language.
For example, 32849002 | Esophageal structure (body structure) | (http://snomed.info/id/32849002) has
PT: Esophageal structure (US)
PT: Oesophageal structure (GB)
A PT for one concept may also be a synonym for another concept.
For example,
84162001 | Cold sensation quality (qualifier value) | (http://snomed.info/id/84162001) has a preferred term of cold
82272006 | Common cold (disorder) | (http://snomed.info/id/82272006) also has a synonym of cold
In both concepts, cold represents a common clinical phrase used to capture the meaning of the concept .
The PT is indicated by the acceptabilityId field, for a particular language or dialect.

Synonym
In SNOMED CT, a synonym (SYN) is a description that is an acceptable way to express the meaning of a concept in a
particular language or dialect, i.e. it is a word or phrase, other than the FSN, that represents a concept. Unlike FSNs,
synonyms are not required to be unique.
Each concept may have one or more synonyms.
For example,
US English synonyms for 22298006 | Myocardial infarction (disorder) | (http://snomed.info/id/22298006) are:
Myocardial infarction
Cardiac infarction
Heart attack
Infarction of heart
MI - myocardial infarction
Myocardial infarct

Modeling
A synonym may not change to, i.e. replace, an existing FSN.

Duplicate terms as synonyms

In most cases, it is unacceptable to add the same term as a synonym to more than one concept. However, some
terms have more than one meaning and can be synonyms for more than one concept.

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When concepts have the same term as synonyms, they are checked to determine whether or not they are
duplicates. If they are duplicates, one concept is inactivated with a historical association link of SAME_AS to the
other concept.
A synonym with a single meaning may be, erroneously, associated with more than one concept. If the concepts are
not duplicates, the synonym should be retained with only one of the concepts and inactivated on the others.

Exceptions
Although uncommon, a term may be acceptable as a synonym for two or more concepts. This depends
on the context.
For example,
Fundus in the context of obstetrics vs ophthalmology

Narrower synonym
When a synonym is more specific than the FSN, it does not have the same meaning, and should be inactivated. The
description inactivation value of 723278000 | Not semantically equivalent component (foundation metadata
concept) | is used.
For example:
FSN: Removal of device (procedure)
SYN: Replacement of prosthetic device (procedure) - more specific meaning than the FSN

Broader synonym
When a synonym is more general than the FSN, and there is no context in which it has the same meaning as the
FSN, the synonym should be inactivated. The description inactivation value of 723278000 | Not semantically
equivalent component (foundation metadata concept) | is used.
For example,
FSN: Sprain (morphologic abnormality)
SYN: Joint injury - more general meaning than the FSN
However, a more general synonym is acceptable when there is a context in which the synonym has the same
meaning as the FSN.
For example:
FSN: Entire fundus uteri (body structure)
SYN: Fundus in the context of obstetrics - same meaning as the FSN

Definitions
A definition is a textual description applied to some SNOMED CT concepts that provides additional information
about the intended meaning or usage of the concept. Definitions are not mandated and are considered for addition
on a case by case basis and if required to differentiate a concept from its related concepts.

Adding a definition to a concept provides additional clarity on its context of use. It "enhances" the definition
provided by the modeled relationships whereby a term can be sufficiently defined logically, but the "words", which
is how many look for and interpret meaning, may imply more or less specificity.
Definitions should be written as complete sentences beginning with a capital letter, ending with a period and
marked CS, this is default for case sensitivity in DEF status.
For example,
The definition for the concept 11530004 | Brittle diabetes mellitus (finding) | (http://snomed.info/id/11530004) is:
Frequent, clinically significant fluctuations in blood glucose levels both above and below levels expected to be
achieved by available therapies.

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The definition should never be contradictory to the modeling.

The example, "raised blood pressure" is a commonly used phrase which in itself is ambiguous. Raised can mean
"higher than a previous measurement"; "on the high side of normal range" or "above reference range". Because of
that ambiguity, we may not be able to create a definition via the logical model, so would need a text definition to
encourage a consistent use of the term.
Thus, if a term may be interpreted in multiple ways, but is intended to mean only one way in SNOMED CT, it needs
a definition.

URLs that point to definition sources are unacceptable.

External references, such as ISBN and PubMed identifiers, are not allowed in SNOMED CT concept
definitions.

General Naming Conventions

In general, names should:
Be consistent and reproducible
Follow natural or human language when possible
Be unambiguous to users
Be clear for translation purposes
Naming conventions should not be based on word order preferences (e.g. to facilitate search or display). Creating
multiple word order variants for these purposes is outside the scope of the International Release of SNOMED CT .

Pre-coordination Pattern
SNOMED CT relies on the rules for usefulness to avoid excessive pre-coordination. (see Does It Belong in
SNOMED CT? (see page 20))
Approved pre-coordination naming patterns have been created and are available at: Pre-coordination
Pattern JIRA Project .

Articles
Descriptions should not include articles such as a, an, and the. There are legacy descriptions that contain articles
such as the that will be corrected over time.
For example,
Use description of |Neoplasm of respiratory tract (disorder)|, not |Neoplasm of the respiratory tract (disorder)|
Use description of |Rupture of diaphragm (disorder)|, not |Rupture of the diaphragm (disorder)|

Abbreviations
Abbreviations are shortened forms of words or phrases. Because they may not be understood by all users, they
allow for misinterpretation. Consequently they are not permitted in fully specified names (FSN). They are not
allowed in preferred terms (PT) or synonyms (SYN) unless they are accompanied by the fully expanded term.

Exceptions
Official names of organism, which is represented as organism preferred term, may include abbreviations. The
abbreviations do not need to be accompanied by the fully expanded term.
For example,

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448945001 |Campylobacter lari subspecies lari (organism)| has a synonym of Campylobacter lari subsp.
Lari
Abbreviated organism part names are allowed in a preferred term (and other synonyms). The abbreviations do not
need to be accompanied by the fully expanded term
For example,
24771000087106 |Antigen of Streptococcus pneumoniae Danish serotype 1 capsular polysaccharide
conjugated to Corynebacterium diphtheriae cross-reacting material 197 protein (substance)|has a
synonym “Streptococcus pneumoniae Danish serotype 1 capsular polysaccharide antigen conjugated
to Corynebacterium diphtheriae CRM197 protein” that includes CRM which is the abbreviated form for
cross-reacting material.

Acronyms
An acronym is a specific type of abbreviation formed from the initial letters of words and is sometimes pronounced
as a word (e.g. AIDS for Acquired Immunodeficiency Syndrome, NICU for Neonatal Intensive Care Unit). Acronyms
can be misinterpreted because they are not fully spelled out and have different meanings in different situations.

Fully specified names

Acronyms are not usually permitted in an FSN. An acronym is allowed in an FSN when it has become a word in its
own right, i.e. included in dictionaries; understood without expansion to its original full form.
For example,
Concept 122456005 | Laser device (physical object) | (http://snomed.info/id/122456005) uses the term "laser",
which originated as an acronym for "light amplification by stimulated emission of radiation"

Preferred terms and synonyms

Acronyms are allowed in a Preferred Term or Synonym when followed by the expanded term. If the a cronym
stands alone (i.e. represents the entire meaning of the description without any other text), it is followed by a space, a
hyphen, and another space, then the expanded term. The first word after the dash should be lower case as per usual
capitalization rules.
For example,
30549001 | Removal of suture (procedure) | (http://snomed.info/id/30549001) has a synonym of |ROS - removal
of suture|
387727008 | Intermittent positive pressure breathing treatment (regime/therapy) | (http://snomed.info/id
/387727008) has synonym of |IPPB - intermittent positive pressure breathing therapy|

If the acronym forms only part of the description's meaning, it is followed by a space, then the expanded term in
parentheses.
For example,
|Nontraumatic AKI (acute kidney injury)| is a synonym for 140031000119103 | Acute nontraumatic kidney
injury (disorder) | (http://snomed.info/id/140031000119103)

Exceptions
The preferred term for imaging procedures involving imaging modalities commonly referred to by an acronym
(such as CT, MRI, SPECT, PET) omits the expanded term after the acronym.
For example,
|CT of head| is the preferred term for 303653007 | Computed tomography of head (procedure) | (http://snomed.
info/id/303653007)

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Eponyms
Eponyms are names that are derived from proper names (usually the person who made the discovery or created the
original description). They are found in many areas of medical terminology, including anatomic structures,
morphologic abnormalities, diseases, findings, and procedures (e.g. Rutherford Morison's pouch, vein of Galen,
Aschoff body, Kell blood group, Down syndrome, Moro reflex, and Whipple procedure).
It is neither desirable nor possible to completely avoid using eponyms in a health terminology; although, if possible,
they should be avoided. This helps to improve clarity of meaning and to facilitate translation to other languages.
Fully specified names (FSN) should be full descriptions, whereas synonyms may be eponymous terms.
For example,
Structure of great cerebral vein (body structure) has the synonym Vein of Galen
Complete trisomy 21 syndrome (disorder) has the synonym Down syndrome
Pancreaticoduodenectomy (procedure) has the synonym Whipple procedure
It is permitted and encouraged to include eponyms as descriptions (non-FSN descriptions) whenever they are
understandable, reproducible, and useful in a given context.

Exceptions
Exceptions require careful consideration since eponyms meanings may change over time. They are allowed when:
The full description is exceptionally long and unwieldy (e.g. Hemi-Fontan operation (procedure) instead of
bidirectional Glenn shunt with end-to-side anastomosis of proximal superior vena cava to right pulmonary
artery with isolation from right atrium).
The eponym is the only precise, clinically relevant name available.
A non-eponymous name would necessarily be vague or subject to misinterpretation (e.g. Hodgkin
lymphoma, Burkitt lymphoma).
A brand name has become an eponym. In this case, some brand names have come to stand for a category of
product and not the particular brand itself (examples in US English: Kleenex, Band-Aid, Popsicle, Dacron and
Teflon).
These proprietary eponyms may be included in the International Release as descriptions (non-FSN
descriptions) if they meet the criteria for international inclusion.
They should follow the same rules as other eponyms. Whenever possible, they should not be included
in FSNs (e.g. plastic adhesive bandage strip for Band-Aid).

Conventions when naming a body structure, substance or organism in a concept in another

hierarchy
When creating the descriptions for a concept (e.g. a disorder concept) that name an entity such as a body structure,
substance or organism, the conventions that are applied for naming the entity in the source hierarchy should be
used.
For example,
11218009 | Infection caused by Pseudomonas aeruginosa (disorder) | (http://snomed.info/id/11218009)
This concept references the organism hierarchy in the causative agent of 52499004 |Pseudomonas aeruginosa
(organism)| and uses that description in the FSN.
337311000119101 | Blepharochalasis of left upper eyelid (disorder) | (http://snomed.info/id/337311000119101)
This concept references the body structure hierarchy in the finding site of |Structure of left upper eyelid (body
structure)| and uses "left upper eyelid" in the FSN.
The descriptions should be context neutral for these foundation hierarchies. Where context is explicit for a disease
or procedure, the preferred term from foundation hierarchies can be used instead. For example, procedure CT of
abdomen indicates that the context of CT imaging is cross-sectional. The procedure site should be modeled with
the cross-sectional abdomen. However, it is not necessary to change 'Computed tomography of abdomen
(procedure)' to 'Computed tomography of cross-sectional abdomen (procedure)'. It is the same reason for the
preferred term 'CT of abdomen'.

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Exception
When defining causative agent attribute for clinical findings and disorders by referring to an organism of sub-
hierarchies 387961004 |Kingdom Animalia (organism)| or 31006001 |Kingdom Plantae (organism)|, the common
name of the organism should be used in the clinical finding/disorder preferred term.

Structure, Structure of
Outside of the body structure hierarchy, concepts should not include the words structure or structure of
in the concept descriptions.
For example,
For the body structure concept, 266005 | Structure of lower lobe of right lung (body structure) | (
http://snomed.info/id/266005), a disorder concept with this body structure is 724056005 | Malignant
neoplasm of lower lobe of right lung (disorder) | (http://snomed.info/id/724056005).
For the body structure concept, 266005 | Structure of lower lobe of right lung (body structure) | (
http://snomed.info/id/266005), a procedure with this body structure is 726425007 | Lobectomy of
lower lobe of right lung (procedure) | (http://snomed.info/id/726425007).

Description Length Limitations

In the rare event that the 255-character limit of the fully specified name is reached, standard naming conventions
may be circumvented in order to adhere to the 255-term string limit. For example, the use of commas may be used
instead of the word “and”.

Case Significance
Most SNOMED CT descriptions begin with an upper case letter in the SNOMED International Authoring Platform.
Generally, the rest of the words in the description should be lower case except for abbreviations, proper nouns, i.e.
names of people, organizations, taxonomic groups (e.g. species, genus, family), etc. The following values, as part of
the SNOMED CT model component domain, provide details.

Case Sensitivity

Case Sensitivity Values Meaning Examples

Indicator

cI 900000000000020002 | First letter of the Family history of Prader-

Only initial character case description may or may Willi syndrome (situation)
insensitive (core not be capitalized while
Born in Australia (finding)
metadata concept) | ( the case of the rest of the
http://snomed.info/id description cannot be Neonatal jaundice with
/900000000000020002) changed Dubin-Johnson syndrome
(disorder)
Penicillin resistant
Streptococcus pneumoniae
(organism)

CS 900000000000017005 | Cannot change any case Down syndrome

Entire term case sensitive in the description
English as a second
(core metadata concept) |
language (finding)
(http://snomed.info/id
/900000000000017005) pH measurement
(procedure)

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Case Sensitivity

mm (qualifier value)
Changing case may
change the meaning of
the term o r is not
commonly used

ci 900000000000448009 | Entire description may be Fracture of tibia (disorder)

Entire term case lower or upper case
Abdominal aorta
insensitive (core
Changing case does not angiogram (procedure)
metadata concept) | (
change the meaning of
http://snomed.info/id Bite of fish (event)
the term
/900000000000448009)
Floor mat (physical object)

Case sensitivity can be changed on an existing description without inactivating it.

Numeric values
Numeric values will not display differently if switched between upper and lower case, so numeric values should be
treated as case insensitive characters in a term.

If a description begins with a numeric value and the word following the number does not begin with a capital letter,
the case sensitivity indicator is ci for Entire term case insensitive.
For example,
The concept 33635003 | Serotonin (substance) | (http://snomed.info/id/33635003) has the synonym, 5-
hydroxytryptamine. The description is recorded in SNOMED CT in lower case, not 5-Hydroxytryptamine, but
the case sensitivity indicator is ci for Entire term case insensitive.

If a description begins with a numeric value and follows with an abbreviation that contains a capital letter, the case
sensitivity indicator is cl for Initial character case insensitive .
For example,
The concept 387407006 | Tioguanine (substance) | (http://snomed.info/id/387407006) has the synonym, 6-TG.
Apply the case sensitivity indicator of cl for Only initial character case insensitive .

Special characters
Special characters such as <, %, >, . , &, ^, will not display differently if switched between upper and lower case, so
numeric values should be treated as case insensitive characters in a term. The rules for numeric values apply
similarly to special characters.
If a description begins with a special character and the word(s) and/or symbol(s) following the special character
begins with a capital letter, the case sensitivity indicator is cl for Initial character case insensitive .
For example,
The concept 277976001 | Less than 35 degrees C (qualifier value) | (http://snomed.info/id/277976001) has the
synonym, <35 degrees C . The description starts with a special character that is case insensitive but contains
an abbreviation "C" for Celsius that is case sensitive, so the case sensitivity indicator applied to the synonym is
cl for Only i nitial character case insensitive .

Greek alphabet characters

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Greek alphabet characters

Words derived from the Greek alphabet, for example, alpha, beta, delta, gamma, omega, and etc. are all
case insensitive wherever they are in the description.

Assessment scales and staging systems

SNOMED CT descriptions representing assessment scales and staging systems should be capitalized per the name
of the scale or staging system. Legacy concepts may not follow this pattern.
For example,
Ages and Stages Questionnaires Third Edition (assessment scale)
Fagerstrom test for nicotine dependence (assessment scale)
National Cancer Institute histologic grading system (staging scale)
Clark system for melanoma staging (staging scale)

Gram staining
Gram staining is a common laboratory technique used to differentiate bacteria based on their cell wall
constituents. Laboratory test results may be Gram positive or Gram negative . The technique was
developed by a Danish physician, Hans Christian Gram. Consequently Gram , when referring to the
technique, should always begin with an upper case G .

Person Naming Conventions

Patient vs Subject
Descriptions should use the word subject, not patient, if required. Subject is broader than patient.
For example,
420058008 | Provider of history other than subject (person) | (http://snomed.info/id/420058008)
Subject refers to the subject of record, who may, in some circumstances, not be the patient.

Caregiver vs Carer
Descriptions with caregiver should be as follows:
An FSN should use caregiver as (one word).
There should be a synonym using carer.
For example,
425578005 | Caregiver able to cope (finding) | (http://snomed.info/id/425578005)
Synonym: Carer able to cope

Plurals

Fully specified names (FSNs)

In general, concepts are represented in the singular, rather than the plural.
For example:
Disorder of lung (disorder), not disorder of lungs
Acute cholecystitis due to biliary calculus (disorder), not biliary calculi
FSNs should not be plural unless the concept necessarily involves multiples.

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Unintended plurals
Unintended plurals might be incorrectly interpreted. An unintended plural is the use of a plural when, in fact, there is
only one entity.
Correct example,
Multiple cranial nerve palsies; the word multiple indicates that there can never be just one, so the plural
palsies is correct
Incorrect example,
Trochlear lesion versus trochlear lesions; users would use this concept to refer to a single trochlear lesion,
thus the plural form would be incorrect

Exceptions
Organizational nodes or grouper concepts may be plural.
For example,
234320004 | Procedures for splenic lesions (procedure) | (http://snomed.info/id/234320004)
194732001 | Diseases of mitral and aortic valves (disorder) | (http://snomed.info/id/194732001), has IS A
195002007 | Multiple valve disease (disorder) | (http://snomed.info/id/195002007)
A concept that necessarily involves multiples should have a plural FSN.
For example,
Bilateral atrophy of testes (disorder)

It is advisable to keep track of these exceptions in a separate subset or using a special term type, so that
they can be excluded when the singular/plural distinction is important for mapping.

Punctuation and Numbers

Legacy content may not adhere to current guidelines and will be updated as resources allow.

Comma ( , )
A comma is allowed in an FSN when required for meaning or to add clarity.
For example,
Computed tomography of head, neck, abdomen and pelvis (procedure)
A comma is not allowed to change sort order for use in the search function.
Unacceptable example,
Frostbite, acute

Apostrophe ( ' )
Eponymous descriptions should not include an apostrophe or final s, unless the name normally ends in s. With rare
exception, a concept with an eponym should have at least one description that follows this rule.
For example,
Down syndrome, a synonym for Complete trisomy 21 syndrome (disorder)
Sjogren syndrome (disorder)
Meigs syndrome (disorder)
When common usage requires it, there should be at least one description that has the apostrophe s. For
descriptions with a possessive apostrophe where the name normally ends in s, the apostrophe should follow the s.

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For example,
Alzheimer's disease (disorder)
Bowen's disease (disorder)
Meigs' syndrome (disorder)

Existing eponymous descriptions with the possessive s, but no apostrophe, need not be inactivated, but
newly added descriptions should either have no s, or else include the apostrophe.

Special character ( <, >, &, %, $, @, # )

The special characters <, >, &, %, $, @, # are not permitted in FSNs. All instances of FSNs with these characters should
be spelled out in full text.
For example,
FD&C Yellow #2 should be FD and C Yellow Number Two
The characters &, %, and # are permitted in preferred terms or synonyms.

The characters @ and $ are not used in any descriptions.

Hyphen and dash ( - )

A hyphen is used to join words and to separate syllables. Hyphens may be used in FSNs. There is no space either
before or after a hyphen.

Hyphens should follow rules of style for the dialect and language in which the descriptions are used as
found in such publications as the Chicago Manual of Style, the American Medical Association’s Manual of
Style, a current medical dictionary, etc.

WIPEDGUIDE-6 (https://jira.ihtsdotools.org/browse/WIPEDGUIDE-6?src=confmacro) COMPLETED

Unless used to prevent ambiguity, punctuation is to be used sparingly.

For example,
Anti-infective agent (product)
Zollinger-Ellison syndrome (disorder)
Zellweger's-like syndrome (disorder)
Tick-borne hemorrhagic fever (navigational concept)
Phospho-2-dehydro-3-deoxygluconate aldolase (substance)
Multidrug-resistant bacteria (organism)
Pandrug-resistant bacteria (organism)
Extended spectrum beta-lactamase-producing bacteria (organism)
A dash may be used to separate two phrases, to contrast values, or to show a relationship between two things. A
dash should not be used in an FSN, with rare exception, because it may obscure the exact meaning of the
description. The dash should be replaced with words that clarify the meaning. A dash is also used to separate an
acronym from its expanded form when no other terms are included in a description.
For example,
273420000 | Disability assessment schedule (assessment scale) | (http://snomed.info/id/273420000) has a
synonym of DAS - Disability assessment schedule

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719977005 | Communication Activities of Daily Living (assessment scale) | (http://snomed.info/id/719977005) has

a synonym of CADL - Communication Activities of Daily Living

Exceptions
When there is a need to distinguish categories from more specific subtypes with the same name, a dash followed by
the word category, may be used.
For example,
416500007 | Malignant glioma - category (morphologic abnormality) | (http://snomed.info/id/416500007)
distinguishes the category of malignant gliomas from those neoplasms that are called 74532006 | Glioma,
malignant (morphologic abnormality) | (http://snomed.info/id/74532006). The neoplasm called malignant glioma
is one of several subtypes of 416500007 | Malignant glioma - category (morphologic abnormality) | (
http://snomed.info/id/416500007), and does not have the same meaning as the category itself.

Colon ( : )
In general, colons should not be used in fully specified names.

Exceptions
Colons are allowed in the FSNs of organisms, substances, or products where the colon is part of the name. They are
also allowed in ratios and in tumor stages.
For example,
Salmonella II 43:g,t:[1,5] (organism)
Lidocaine hydrochloride 1.5%/epinephrine 1:200,000 injection solution vial (product)
pT3: tumor invades adventitia (esophagus) (finding)
Colons may be allowed in non-FSN descriptions.
For example, to separate an abbreviation from the rest of a name or a specimen from the finding
Urine: turbid (finding)

Forward slash ( / )
The forward slash should not be used in FSNs. When the slash is part of the authoritative name (e.g. representation
of heterozygosity in hemoglobinopathies), a hyphen (no space before or after) is used in the FSN. The forward slash,
without spaces, may be used in a preferred term or synonym.
For example,
FSN: Sickle cell-hemoglobin C disease (disorder)
SYN: Hemoglobin S/C disease
FSN: Per cubic millimeter (qualifier value)

SYN: /mm3

Exceptions
A forward slash may be used to represent units of measure, official enzyme names, and laboratory test results. They
may also be used in and/or when part of FSNs. There should be no space either before or after the slash.
For example,
Nitroglycerin 0.3mg/hr disc (product)
Ibuprofen 5%/Levomenthol 3% gel (product)
Milligram/deciliter haptoglobin (qualifier value)
Bone structure of head and/or neck (body structure)

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A forward slash may be allowed in non-FSN descriptions in a variety of contexts. Some common examples of use
are in acronyms with findings, and as an abbreviation meaning and/or concepts.

Plus sign ( + )
The plus sign is generally discouraged for use in descriptions, and legacy content still contains this symbol.
However, some uses are allowed. Plus signs may be found in the product, disposition, and substance hierarchies.
For example,
| H+/K+-exchanging ATPase inhibitor| is an acceptable synonym for 734582004 | Hydrogen/potassium
adenosine triphosphatase enzyme system inhibitor (disposition) | (http://snomed.info/id/734582004).

Caret symbol ( ^ )
A pair of caret symbols is used to enclose character strings that should display as superscript.
For example,
Technetium Tc^99m^ labeled carbon (substance)
Blood group antigen Sd^a^ (substance)
The single caret is used to represent exponents, i.e. powers of, in alignment with the Unified Code for Units of
Measure (UCUM) guidance on the use of powers of ten.
For example,
10^3 for the third power of ten

Pipe character ( | )
A description cannot contain a pipe character, |. Since the | is used to indicate the beginning and end of a
description, it may cause confusion.

Umlaut ( ¨ )
An umlaut should only be accepted for terms that do not have equivalences in English. Synonyms without umlauts
should be added to facilitate searching in English.
For example,
83901003 | Sjögren's syndrome (disorder) | (http://snomed.info/id/83901003) and one of its synonyms, Sjogrens
syndrome

Roman numerals versus Arabic numbers

Use the most common representation found in literature for the fully specified name. Use the alternative
representation as a synonym, if it is also represented in the literature. If neither representation is common, use the
Arabic representation.
For example, in the AMA Manual of Style, cancer stages are expressed with the use of capital Roman numerals: stage
I, stage II, stage III, stage IV. The term, "stage 0", usually indicates carcinoma in situ. Histologic grades are expressed
with Arabic numerals, e.g., grade 2.

Sentence Types
Concepts should be names or short noun phrases. Full statements or sentences are unacceptable.
Procedure concepts should not contain phrases that can be categorized as a sentence function type, i.e. imperative,
declarative, interrogative, or exclamatory. A procedure description should be a noun phrase that names the
procedure, and should not contain information that it was done, or is to be ordered, carried out, or planned.
For example,
11227005 | Excision of ganglion of tendon sheath of hand (procedure) | (http://snomed.info/id/11227005) is a
noun phrase giving the proper description for the procedure

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Unacceptable example,
Hand tendon ganglion excised (situation) indicates the procedure was done, as a past tense declarative
statement
This is a situation with explicit context, not a procedure.

US vs. GB English
All fully specified names (FSN) should be represented in US English. When there is a difference between the US and
GB spelling, there should be US and General British (GB) preferred terms (PT) and/or synonyms (SYN).
For example:
FSN: Benign tumor of endocrine pancreas (disorder)
PT-US: Benign tumor of endocrine pancreas
PT-GB: Benign tumour of endocrine pancreas

Proper nouns
Where an FSN represents the name of an organization or trademarked name, a synonym with variant GB
or US spelling is not required .

References for Spelling

References Notes

US-GB differences Wikipedia, the free encyclopedia* First point of reference

*Note: Wikipedia may be used as Provides a summary for authors,
a starting point, or source, for addresses many US-GB spelling
authoritative references, but not differences, and provides references
as an actual reference

US Medical English Stedman's Medical Dictionary NA

Merriam-Webster Online
Dictionary
American Medical Association
(AMA) Manual of Style

GB English Dorland's Medical Dictionary - NA

medical terminology
Chambers 21st Century
Dictionary - general

Oxford English Dictionary spelling is different from British English. A summary of the points of difference
can be found at http://en.wikipedia.org/wiki/Oxford_spelling_. In those cases where British English and
Oxford English Dictionary differ, SNOMED CT follows the British English spelling.
The addition of an Oxford English Dictionary term is allowed but not required. When added it should be
marked as acceptable in the British English dialect. In some cases it is also accepted or preferred in US
English.

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Principles for selecting preferred spelling variants

SNOMED CT may include (or add) more than one description, each with a different spelling for a given concept.
That is if the above references provide evidence of acceptability in the dialects for which they are being added.
For spelling of preferred terms in a dialect, where the reference sources provide multiple options, a judgment about
the most common spelling may be needed. This may be determined by reviewing journal articles containing the
word in question.
Articles should be from highly cited journals, e.g BMJ (for British English) or NEJM or JAMA (for US English).
For concepts that are not clinical, appropriate scientific journals should be consulted, e.g. Science (US
publisher) or Nature (UK publisher).

Action Verbs
Action verbs should be written in noun form within SNOMED CT descriptions. This most often means the verb will
end with a suffix of –tion, -sion, -ment, -al, -ence, or -ance.
For example,
Destruction instead of destroy
Incision instead of incise
Replacement instead of replace
Removal instead of remove
Maintenance instead of maintain
However, the root form of the verb may be used when it does not make a word when ending in noun suffixes.
For example,
Control
Release
Care
Lastly, the verb with a suffix of –ing may be used when the root form of the verb may cause ambiguity in the
meaning, i.e. the root form of the verb could also be a physical object.
For example,
Wiring instead of wire
Suturing instead of suture
Splinting instead of splint
Mapping instead of map
Grafting instead of graft
Exceptions,
Common usage may dictate some exceptions.
For example,
Repair instead of repairment
Although ‘repairment’ may be considered a valid word, its use has fallen out of common usage in comparison to
‘repair’.

Check for approved and unapproved naming patterns on the pre-coordination JIRA project page at Pre-
coordination Pattern JIRA Project.

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Past tense
A past tense verbal phrase should not be used to name a procedure, since it indicates that the procedure was done
in the past.
Unacceptable example,
Hand tendon ganglion excised indicates the procedure was done, as a past tense declarative statement.
However, the following is an acceptable example using a noun phrase,
11227005 | Excision of ganglion of tendon sheath of hand (procedure) | (http://snomed.info/id/11227005)

Situation hierarchy
Existing descriptions containing past tense verbs should be moved to the 243796009 | Situation with
explicit context (situation) | (http://snomed.info/id/243796009) hierarchy.

General Modeling

When to create a template

Less than 50 concepts affected; no template required; check existing templates could be generalised and
/or look to add some elements as optional rather than mandatory.

SNOMED CT is arranged as a polyhierarchy. A hierarchy is defined as an ordered organization of concept codes

linked together through IS A relationships. Concept codes are linked to their more general parent concept codes
directly above them in a hierarchy. Concepts with more general meanings are usually located at the top of the
hierarchy and then at each level down the hierarchy the meanings become increasingly more specialized.
For general modeling information, use the following links to jump to the following pages:

Templates
In addition to the guidance found in the Editorial Guide, please see information on the use of templates at SNOMED
CT Modeling Templates and Description Patterns.
Templates are created by authors in an attempt to standardize the modeling, naming, case significance, etc. of
certain subhierarchies of the terminology, though it is recognized that not every concept may conform to a
prescribed pattern. The modeling approach may be difficult to apply in all cases, but domain-specific templates are
being developed to ensure modeling consistency and accuracy.

Changes to Components
Concepts, descriptions, and target values may be changed for a variety of reasons.

Concept Inactivation

Concept inactivation values

Depending on the reason for inactivation, a specific Inactivation reason has to be selected.

Inactivation reason Association type Notes

Ambiguous Possibly equivalent to

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Inactivation reason Association type Notes

The concept has been made inactive because

it is inherently ambiguous. This may be
because of an incomplete fully specified name
or because it has several associated terms that
are not regarded as synonymous or partially
synonymous

The possibly equivalent target is an active

concept that represents one of the possible
meanings of the inactive concept
Multiple rows may be used to refer to each of
the possible replacement targets for the
ambiguous concept
Previously referred to as May Be A

Ambiguous concepts with a single target

A single target may be justified in the following
situations:
If one of the meanings of the
ambiguous concept is not clinically
useful
The FSN represents a classification
concept, such as ‘other’, ‘NOS’

C (http://snomed.info/id Moved to association reference Applies to a component that has been moved
/900000000000524003) set (foundation metadata to, or is pending a move to another
omponent moved concept) namespace
elsewhere
The target component identifies the target
namespace, not the new component

Duplicate component Same as association reference The concept has been made inactive because
set (foundation metadata it has the same meaning as another concept
concept)
The target component identifies the active
component that this component duplicates

Erroneous component Replaced by association The concept has been made inactive because
reference set (foundation it contains an error
metadata concept)
The target component identifies the active
component that replaces this component

Limited component No longer in use and no Inactivation reason of LIMITED/WAS_A is not

requirement to retain allowed for any new content inactivations after
the July 2018 release.
When changes are made to a historical
relationship for a concept that was previously
inactivated using WAS_A, effort will be made
to assign a new historical relationship that
facilitates traceability of the concept (e.g.
DUPLICATE or AMBIGUOUS)

Outdated component

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Inactivation reason Association type Notes

Replaced by Association The concept has been made inactive because

reference set (foundation it is an outdated concept that is no longer used
metadata concept)

Non-conformance to No association required Applies to a concept which does not adhere to

editorial policy the Editorial guidelines

Inactivation of duplicate concepts

Prior to inactivation
Check to see if the two concepts are true duplicates, i.e. semantically equivalent.
Decide if the semantic meaning of the two concepts is the same.
Review ancestors and descendants (if any) of the concept. Are they inconsistent with what is implied by the
FSN? If so, inactivate the concept.

Inactivation
Keep the more specific FSN and keep the concept ID.
Note: Implementers do not see the modeling. Hence there should be more weight in the meaning of
the FSN, rather than the underlying modeling.
If appropriate, add the inactivated FSN as a synonym for retained concept.
Add the synonyms from the inactivated concept, where they are semantically equivalent,

Consider
Inactivating the concept with fewer subtypes. This will simplify the process and minimize the amount of
rework required.
If needed, the retained FSN should be reworded to align with current policy. If required, modeling should also
be corrected.

Inactivated concept
Add the inactivated descriptions as synonyms (if the meaning is the same) to the retained concept.
The inactivated concept should be marked as ambiguous, if it has an unclear meaning.

Inform the requestor (if there is a request), as soon as possible, as to which concept is inactivated.

Inactivating classification-derived terms

SNOMED CT has many concepts derived from classifications that describe a clinical condition with an added
exclusion, such as 90768003 |Contusion of brain without open intracranial wound (disorder)|. These “without x”
terms are not clinically useful. When inactivating these concepts, use Ambiguous as the inactivation reason with the
association type of Possibly equivalent to the parent concept, which is the clinical condition without any context.
For example,
When inactivating 156322003 |Pilonidal sinus without abscess (disorder)|, use the inactivation reason Ambiguous
with Possibly equivalent to association type pointing to |Pilonidal sinus|.

Non-conformance to editorial policy

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Non-conformance to editorial policy

The inactivation reason of “Non-conformance to editorial policy” can be used when there is no
replacement, the concept is not clinically useful, or when the concept violates such policy, e.g. inclusion
of numeric ranges, X with Y with Z, etc .

Description Inactivation
Description inactivation values
Depending upon the combination of the type of component and the reason for inactivation, a specific Inactivation
reason has to be selected.

Inactivation value Definition Example

Not semantically A description does not represent the same The FSN Removal of device (procedure)
equivalent component meaning as the concept's Fully Specified has the synonym, Replacement of
(foundation metadata Name (FSN) prosthetic device (procedure). The
concept) synonym has a more specific meaning
than the FSN, so it should be inactivated

Outdated component A component is no longer current, useful, The synonym Funny looking kid was
(foundation metadata appropriate or acceptable inactivated from 112630007 | Abnormal
concept) facies (finding) | (http://snomed.info/id
/112630007)

Erroneous component A component contains a technical error Case significance changes, Alpha where
(foundation metadata the lower case a should have been used
concept)
Spelling errors, a description where
Asthma is misspelled Assthma

Nonconformance to A component fails to comply with the The concept Urine: turbid (finding) was
editorial policy current editorial guidance inactivated and replaced by 167238004 |
component Turbid urine (finding) | (http://snomed.info
(foundation metadata /id/167238004)
concept)

Order of selection of inactivation values

When there is more than one reason to inactivate a description, the order of preference for the inactivation value is
as follows:

1. 723278000 | Not semantically equivalent component (foundation metadata concept) | (http://snomed.info/id

/723278000)

2. 900000000000483008 | Outdated component (foundation metadata concept) | (http://snomed.info/id

/900000000000483008)

3. 900000000000485001 | Erroneous component (foundation metadata concept) | (http://snomed.info/id

/900000000000485001)

4. 723277005 | Nonconformance to editorial policy component (foundation metadata concept) | (http://snomed.

info/id/723277005)

Considerations for range Concepts

Concepts that are used as a target value in an attribute relationship impact the placement of the source concept of
the relationship. Some concepts, for example, those in the Qualifier value hierarchy, are created to support the
definition of other concepts.

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Review after addition of new attribute value

Creation of a new concept that will be used as the target value in an attribute relationship requires an
author to determine if there are active concepts in the domain hierarchy that should also use the new
concept as a target value.

For example,
The creation of a concept 713295009 | Surgical replacement - action (qualifier value) | (http://snomed.info/id/713295009
) would require a review of current active concepts that represent surgical replacement procedures; that were
previously modeled with the attribute relationship Method = Replacement - action.
A concept that represents a surgical replacement procedure that currently has the relationship Method =
282089006 | Replacement - action (qualifier value) | (http://snomed.info/id/282089006) , would require inactivation of
the relationship and creation of a new relationship Method = 713295009 | Surgical replacement - action (qualifier
value) | (http://snomed.info/id/713295009) .

Conjunction and Disjunction

In SNOMED CT, and is used in descriptions to represent the operator for logical conjunction. Concepts with the
disjunctives (or, and/or) are unacceptable. Instead, there should be separate concepts. There are limited exceptions
where and/or is used to represent the operator for inclusive disjunction. This helps to avoid confusion with the
literal use of or in common language, i.e. only one of two operands is true; rarely both operands are true.

Conjunction and Disjunction

and or and/or

SNOMED Conjunction: And Not allowed in Inclusive disjunction: And/or

CT SNOMED CT
A set of operands is true, if A set of operands is true, if and,
and, only if all of its operands only if one or more of its operands
are true is true
A and B are true Either A or B is true
or
Both A and B are true

Anatomical structure hierarchy

Conjunction and disjunction are commonly used in the anatomical structure hierarchy.
For example, 419605007 | Structure of ankle and/or foot (body structure) | (http://snomed.info/id/419605007) represents
adjacent regions of ankle and foot by a single concept. It is inclusive disjunction because any structures of ankle,
foot, or both are true subconcepts. Entire ankle and foot as a conjunction means the ankle and foot as a whole. The
concept represents the entirety of this single region though there is no dedicated name.
Following the anatomy SEP (Structure/Entire/Part) model (full discussion in appendices), structure means all or any
part of an anatomic entity, which is inclusive disjunction. Structure of ankle and foot represents all or part of entire
ankle and foot. Therefore, a ny structures of ankle, foot, or both are true subconcepts of structure of ankle and foot.
Structure of ankle and foot has the same meaning as structure of ankle and/or foot. The use of and/or is actually
redundant for structure concepts like 419605007 | Structure of ankle and/or foot (body structure) | (http://snomed.info
/id/419605007).

Inclusive disjunction
Structure of ankle and foot was previously used. These descriptions were changed to and/or to explicitly
indicate inclusive disjunction. This supports users who are unfamiliar with the interpretation of structure
in the SEP model.

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And
The and represents conjunction in disorders and procedures that can be interpreted as co-occurrent. It can be read
as both in common usage. It would be all if it refers to more than two disorders or procedures.
For example,
75857000 | Fracture of radius AND ulna (disorder) | (http://snomed.info/id/75857000) represents the occurrence
of a fracture of radius and a fracture of ulna at the same time or event. In other words, fracture of both radius
and ulna. The concept should be modeled using two finding site relationship groups: Bone structure of radius
in one and Bone structure of ulna in the other.

And/or
The and/or represents disjunction in disorders and procedures, i.e. one or more of the parts is involved.
For example,
65966004 | Fracture of forearm (disorder) | (http://snomed.info/id/65966004)
The concept does not specify which bone of forearm is fractured. It is a break in one or both of the radius and/or
ulna per the ICD definition . It would subsume fracture of radius, fracture of ulna, and fracture of both radius and
ulna.

Modeling
The use of and/or in a description with disjunction should be lower case.

General Concept Inclusions (GCIs)

Draft Guidance
See the background, use cases, and examples for general concept inclusion axioms as well as explanation of the
definition status at https://docs.google.com/document/d/1-Tvswkw5USXydVWpBsT3iORdOFzx3qKAyownS4Enor4
/edit?usp=sharing

Authoring Platform User Guide for GCIs

Reference the SNOMED International Authoring Platform User Guide for the technical information that describes
adding an additional axiom and adding a general concept inclusion, https://confluence.ihtsdotools.org/display
/SIAPUG/Authoring+-+Description+Logic+%28DL%29+Support+Features?src=contextnavpagetreemode

GCI-Modeled Primitive Ancestor

General concept inclusions allow multiple definitions of a concept. A group of subtypes may be defined using GCIs
and be considered subtypes of the parent concept without fully defining that parent concept. That parent concept
could have multiple definitions, each of which is valid but none of which completely describes the parent concept
on its own.
When modeling a concept that will be inherited by a GCI-modeled concept, there is no need to add the GCI-
modeled concept as a parent even if that GCI concept is primitive. The benefit of GCIs is obtaining correct
classification without having to state an intermediate primitive. The concept will be inherited under the GCI-
modeled concept even though it is not asserted as a primitive parent.
For example,
Thunderstorm asthma (disorder) below shows incorrect modeling stating two primitive parents. Allergic
condition (finding) is modeled with GCI as notified by the salmon pink color. The diagram on the left shows
the inferred view.

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Because GCI-modeled primitive parents are unnecessary to state in the model, the diagram below shows the correct
modeling of the concept, which is the absence of Allergic condition (finding) as a parent, and yet the inferred view
diagram on the left is still the same as compared to the incorrectly modeled diagram above.

Points to Consider
GCIs are not restricted to particular hierarchies; they can be used as applicable in any hierarchy that has a
concept model.
The Authoring Platform does not currently have the ability to create templates that include GCIs.

Grouper Concept
For hierarchies with a concept model, the usefulness of fully-defined groupers is limited to convenience groupings
based on particular use cases. They may be added if they provide demonstrable benefit to organizing and
navigating the terminology.
Grouper concepts provide a definition for subtypes that are always and necessarily true. The grouper concept must
be sufficiently defined and clinically useful for the purpose of organizing content for an intensional reference set (e.
g. disease of colon and all of its descendants) or in Expression Constraint Language (ECL), 128524007 | Disorder of
colon (disorder) | (http://snomed.info/id/128524007).

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Anatomy concepts
Anatomy concepts have separate rules.

Navigational concepts
Grouper concepts should not be confused with navigational concepts . N avigational concepts were created to
group other concepts without explicit regard for defining attributes (since there were none). Their purpose was to
provide top level groupers for subsets and reference sets used in implementations. Because the Reference Set
mechanism is now available, there is no longer a need for navigational concepts in the International Release;
however, they can be added at the national or lower level.
In the past, there was an indiscriminate move of concepts in and out of the navigational concept hierarchy based
arbitrarily on use cases by those users organizing concepts based on a particular classification that was wanted. The
navigational concept hierarchy was useful to group things into a particular domain. The problem is that many of
these are domain-specific and cannot be generalized. For example, mosquito-borne diseases will vary depending on
the location of the user. It is difficult to classify the complete instance of these as well. Potential children would have
to be manually assigned.
Because this is a primitive hierarchy and subtypes will not auto classify, much work would be required to reorganize
hierarchies and maintain the use of navigational concepts. Inactivating concepts may be met with requests to
create intermediate primitives. The Content Managers Advisory Group [CMAG] at Use of navigational concepts is
being consulted regarding current use of navigational concepts.
As 363743006 | Navigational concept (navigational concept) | (http://snomed.info/id/363743006) is within the
370115009 | Special concept (special concept) | (http://snomed.info/id/370115009) subhierarchy, please see that section
of the Editorial Guide at Special Concept* (see page 247).

Intermediate Primitive Groupers

Intermediate primitive groupers are sometimes necessary when the concept model is not robust enough to support
the full definition of a subset of terms.
For example,
Not robust enough to handle the needs of genomics (i.e. genetic diseases for which we cannot state, the
majority of cases of this disease present with X)
Where there are variances in the clinical manifestations
However, intermediate primitive groupers add a substantial management burden, thus they are discouraged. They
may be added on a case-by-case basis and with approval from the Head of Terminology or the Principal
Terminologist.

Rules for grouper concepts

A grouper concept that is added to SNOMED CT must adhere to the following rules:
The concept must not be created with the hierarchical tag, (navigational concept).
The concept must use the semantic tag for the relevant hierarchy e.g. (finding), (procedure).
The concept must not have stated subtypes. All subtypes must be inferred by the classifier.
The grouper concept will ONLY be added if it can be sufficiently defined.
Where grouper concepts already exist, the following criteria apply:
If it can be sufficiently defined, remodel it and reassign existing stated subtypes to a new proximal primitive
parent.
Identify primitive concepts that cannot be sufficiently defined for additional review.

Modeling

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If the addition of a grouper concept duplicates a concept in the 363743006 | Navigational concept
(navigational concept) | (http://snomed.info/id/363743006) hierarchy, the navigational concept should be
inactivated.

Sufficiently Defined vs Primitive Concept

Sufficiently defined
A concept is sufficiently defined if its defining characteristics are adequate to define it relative to its immediate
supertypes. A sufficiently defined concept is defined in the context of its hierarchy. See main glossary entry for
sufficient definition.

Primitive
A concept which is not sufficiently defined is primitive. A primitive concept is a formal logic definition that is
inadequate to distinguish it from similar concepts. A primitive concept does not have enough defining relationships
to computably distinguish it from more general concepts (supertypes).

Proximal Primitive Modeling

See glossary for definition here: proximal primitive (PP)
For some, but not all concepts, it is a top level concept e.g. Procedure.
The proximal primitive supertype may also be an intermediate primitive concept located between the top
level concept and the concept in question.
There may be more than one proximal primitive supertype for a concept.
The approved modelling approach is to use:
Proximal primitive supertypes
Attribute-value pairs sufficient to define the meaning
An attribute-value pair is explicitly stated for the concept, even if it is already present for a supertype
concept.
Attribute-value pairs are grouped as required.
The classifier infers all appropriate proximal supertypes. With sufficiently defined concepts the subtypes are also
inferred.
For example,
The stated view of 702499000 | Computed tomography of humerus (procedure) | (http://snomed.info/id
/702499000). The PP supertype for this concept is 71388002 | Procedure (procedure) | (http://snomed.info/id
/71388002). It has been modeled with one stated supertype and two attribute value pairs in a relationship
group.

Figure 1: Stated view

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The inferred view shows the logical definition of the concept. By using the stated relationships (for this concept and
other concepts currently in the terminology), the classifier infers three defined proximal supertypes:
Radiography of humerus (procedure)
Computed tomography of upper arm (procedure)
Computed tomography of bone (procedure)

Figure 2: Inferred view

Multiple potential primitive supertype concepts

Where more than one potential primitive supertype is identified for a concept, authors should check the primitive
supertypes for subsumption of one or more other primitive supertypes. Any subsuming concept is not a PP
supertype.
For example,
There is more than one potential primitive supertype for 421095001 | Allergic disorder by body site affected
(disorder) | (http://snomed.info/id/421095001). However, 64572001 | Disease (disorder) | (http://snomed.info/id
/64572001) is subsumed by 404684003 | Clinical finding (finding) | (http://snomed.info/id/404684003), therefore
64572001 | Disease (disorder) | (http://snomed.info/id/64572001)is the proximal primitive supertype concept.

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GCI-Modeled primitive supertypes

For information on the effect of GCIs on modeling primitive supertypes, see General Concept Inclusions (GCIs), GCI-
Modeled Primitive Ancestor (see page 53).

Intermediate Primitive Concept Modeling

Concepts that cannot be sufficiently defined by necessary conditions are called primitive concepts.

Primitive concepts cannot have subtypes automatically assigned by the classifier, unless a sufficient condition for
that concept exists. Relevant concepts that are subtypes of a primitive concept in the taxonomy must be manually
assigned an IS A relationship to that concept.
When a primitive concept is a child of one or more concepts and a parent of one or more concepts, it is known as
an intermediate primitive.
For example,
116223007 | Complication (disorder) | (http://snomed.info/id/116223007)
Without a stated IS-A relationship to the proximal primitive concept, |Complication (disorder)|, a concept will not
classify as a subtype of |Complication|. Hence, all relevant subtypes will not be classified as complications.
Identifying all subtypes is important when creating a subset or when Identifying relevant content during data
retrieval. Therefore, when adding new concepts, potential primitive parents need to be identified and the IS_A
relationship stated.
Consistent assignment of subtypes to intermediate primitive concepts is challenging. To find a possible intermediate
primitive parent, it may be necessary to view the authoring form of several concepts that should be siblings of the
new concept. Authors should also check for a possible intermediate primitive supertype among the descendants of
the most proximate defined parent(s) under which the new concept would be expected to classify as an inferred
subtype.
Given the manual burden that intermediate primitives impose, the creation of new intermediate primitive concepts
in the international edition is prohibited unless:
There is no other option and the concept is clinically necessary.
The impact of adding the concept has been fully explored and understood.
The impact is manageable and there is a management plan, including an extensional definition for the direct
sub-concepts.
For the International Release, such requests are assessed case-by-case.

Relationship Group
A relationship group combines an attribute-value pair with none, one, or multiple attribute-value pairs in order to
refine the meaning of a concept.
A single relationship group containing only one attribute value pair can exist.
When an attribute-value pair is restricted to a single group with no other attribute-value pairs allowed,
the attribute-value pair is described as being "self-grouped".
Multiple attributes-value pairs may be grouped together in relationship groups, and multiple relationship
groups may be created, to sufficiently define concepts.
When creating new concepts or revising existing ones, each attribute type included in a relationship group
may only be present once, e.g. two Associated morphology attributes cannot be in the same relationship
group.
Relationship groups originated to add clarity to:
Clinical finding concepts which require multiple Associated morphology attributes and multiple
Finding site attributes; and
Procedure concepts which require multiple Method attributes and multiple Procedure site attributes.
Relationship groups are not limited to Clinical finding and Procedure concepts.
There is no limit to the number of relationship groups that may be added to a concept.

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Modeling
As with all authoring activities, grouping of attribute-value pairs is performed in the stated view.

Ungrouped attributes
An attribute-value pair that is not in a relationship group is considered to be in a group on its own. When attribute-
value pairs are not grouped, their meanings are interpreted separately. For example, in the following diagram the
Associated morphology is Hemorrhage and the Finding site is Uterine structure. However, it cannot be interpreted
that the site of the Hemorrhage is the Uterine structure.

Figure 1: Inferred view of ungrouped attributes values of Hemorrhage (morphologic abnormality) and Uterine
structure (body structure)
When the attributes are grouped, the relationships imply meaning towards each other. To continue the example
above for 44991000119100 | Abnormal uterine bleeding (disorder) | (http://snomed.info/id/44991000119100), the
following diagram shows the Associated morphology of Hemorrhage and the Finding site of Uterine structure in a
relationship group together. The grouping can be interpreted that the site of the hemorrhage is the uterine
structure.

Figure 2: Inferred view of grouped attribute values of Hemorrhage (morphologic abnormality) and Uterine structure
(body structure)
Note the difference in the inferred parents between the ungrouped and grouped attributes. This is explained in
more detail below.

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Impact of relationship grouping on inheritance

Relationship groups refine inheritance, i.e. a grouped set of attributes is more specific than the same attributes that
are not grouped. This is important when considering subsumption. The following diagrams demonstrate the impact
of grouping, or failing to group, consistently using the concepts 50434004 | Excision of lesion of aorta (procedure) | (
http://snomed.info/id/50434004) and one of its supertypes, 63296004 | Excision of aorta (procedure) | (http://snomed.info
/id/63296004) .

The meaning of the supertype concept, 63296004 | Excision of aorta (procedure) | (http://snomed.info/id/63296004)
(where the relationships are grouped) is interpreted as a procedure with an excision on the aortic structure. This is
because 405813007 | Procedure site - Direct (attribute) | (http://snomed.info/id/405813007)and 260686004 | Method
(attribute) | (http://snomed.info/id/260686004) are grouped.

Figure 3: Inferred view of Excision of aorta (procedure) with grouping of attribute-value pair
In the following diagram, the more general supertype concepts, 65801008 | Excision (procedure) | (http://snomed.info
/id/65801008) and 118809006 | Procedure on aorta (procedure) | (http://snomed.info/id/118809006) are the proximal
supertype concepts.
50434004 | Excision of lesion of aorta (procedure) | (http://snomed.info/id/50434004) is a logical subtype of 63296004 |
Excision of aorta (procedure) | (http://snomed.info/id/63296004). However, the attributes of the concept 50434004 |
Excision of lesion of aorta (procedure) | (http://snomed.info/id/50434004) are not grouped. Thus, the classifier interprets
the definitions as non-related and 50434004 | Excision of lesion of aorta (procedure) | (http://snomed.info/id/50434004)
is not inferred as a subtype of 63296004 | Excision of aorta (procedure) | (http://snomed.info/id/63296004). This is
because the attribute-value pairs in the subtype concept are not grouped, i.e are not explicitly stated. From a
machine-processing perspective, each attribute value pair is considered a group on its own, i.e. there is an excision
but nothing else is known about the excision. This results in the concept, 63296004 | Excision of aorta (procedure) | (
http://snomed.info/id/63296004), being interpreted more broadly.

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Figure 4: Inferred view of Excision of lesion of aorta (procedure) without grouping of attribute-value pairs
In the following diagram the attributes of the concept 50434004 | Excision of lesion of aorta (procedure) | (
http://snomed.info/id/50434004) are grouped. An author that explicitly states that the excision is of a lesion found in the
aortic structure, by grouping the attribute-value pairs, provides the necessary information for the classifier. This
enables 50434004 | Excision of lesion of aorta (procedure) | (http://snomed.info/id/50434004) to be inferred as a
subtype of 63296004 | Excision of aorta (procedure) | (http://snomed.info/id/63296004).

Figure 5: Inferred view of Excision of lesion of aorta (procedure) with grouping of attribute-value pairs

Same attributes in separate relationship groups

Each relationship group should only contain one instance of an attribute. This is because two of the same attributes
in a relationship group is not the same as one attribute with one target value that captures the combined meaning
of the target values, as illustrated in the following diagram.

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Two Finding site attributes are required to support the location of 53627009 | Closed fracture of radius AND ulna
(disorder) | (http://snomed.info/id/53627009). Each 363698007 | Finding site (attribute) | (http://snomed.info/id/363698007)
and its respective target value are placed in a relationship group with the attribute 116676008 | Associated
morphology (attribute) | (http://snomed.info/id/116676008) with its target value of 20946005 | Fracture, closed
(morphologic abnormality) | (http://snomed.info/id/20946005).

Figure 6: Inferred view of Associated morphology (attribute) with its value of Fracture, closed (morphologic
abnormality) in two separate relationship groups

Procedure hierarchy
In the 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002) hierarchy, a relationship group is usually a
way of combining attributes about a particular method.
In the concept 302619004 | Cholecystectomy and exploration of bile duct (procedure) | (http://snomed.info/id
/302619004) in the following diagram, the relationship groups clarify that there is exploration of the bile duct and
excision of the gallbladder. Without the relationship groups, the appropriate relationships between the attributes
would be unclear, i.e. the exploration of the bile duct versus gallbladder and the excision of the bile duct versus the
gallbladder.

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Figure 7: Inferred view of a Procedure hierarchy relationship group: combining attributes around Method (attribute)

Modeling
When there is no Method stated, the 363704007 | Procedure site (attribute) | (http://snomed.info/id
/363704007) (or its subtype either Procedure site-direct or Procedure site-indirect) is always grouped with
405816004 | Procedure morphology (attribute) | (http://snomed.info/id/405816004) (or its subtype either
Direct morphology or Indirect morphology) for that site.

The 260870009 | Priority (attribute) | (http://snomed.info/id/260870009) is to be grouped on its own, or "self-

grouped", as the priority of a procedure applies to the entire procedure and not the specific elements of
the procedure.

Procedures with intent

The 363703001 | Has intent (attribute) | (http://snomed.info/id/363703001) should only be applied where the intent of
the procedure is explicit in the FSN e.g. 61887001 |Diagnostic procedure on tendon sheath (procedure)|. The
attribute should be grouped with the attributes that represent the procedure with that intent.
For example, 258174001 | Imaging guidance procedure (procedure) | (http://snomed.info/id/258174001) has the
363703001 | Has intent (attribute) | (http://snomed.info/id/363703001) grouped with the |Method (attribute)|.

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This policy has yet to be fully applied. Legacy concepts exist without the 363703001 | Has intent (attribute) | (
http://snomed.info/id/363703001) being grouped, especially in the areas of diagnostic and therapeutic intent.

Clinical Finding/Disorder hierarchy

In the Clinical finding hierarchy:
The 363698007 | Finding site (attribute) | (http://snomed.info/id/363698007) and 116676008 | Associated
morphology (attribute) | (http://snomed.info/id/116676008) attributes are always grouped when both are present
and related.
As with Procedure relationship groups, when there is more than one 363698007 | Finding site
(attribute) | (http://snomed.info/id/363698007) or 116676008 | Associated morphology (attribute) | (
http://snomed.info/id/116676008) attribute, then more than one relationship group is required.

246454002 | Occurrence (attribute) | (http://snomed.info/id/246454002)concept and/or the 246075003 |

Causative agent (attribute) | (http://snomed.info/id/246075003) attributes, that are also stated and related
to the 363698007 | Finding site (attribute) | (http://snomed.info/id/363698007) and 116676008 | Associated
morphology (attribute) | (http://snomed.info/id/116676008) attributes, should be included in that
relationship group.
As in the following diagram, when the 246075003 | Causative agent (attribute) | (http://snomed.info
/id/246075003) attribute is an organism, the 370135005 | Pathological process (attribute) | (
http://snomed.info/id/370135005) attribute is also included in that relationship group, with the
target value of either 441862004 | Infectious process (qualifier value) | (http://snomed.info/id
/441862004) or 442614005 | Parasitic process (qualifier value) | (http://snomed.info/id/442614005).

The Interprets and Has interpretation attribute-value pairs are always grouped together where both are
present and related to each other. These two attributes and their values are often used in defining a Clinical
finding concept by delineating the observation results or describing the analysis used to determine the
observation. Interprets and Has interpretation attributes are not grouped with any other attributes.
The Finding method and Finding informer attribute pairs are also grouped together where both are present
and related to each other.

Relationship group clarification

A relationship group that uses before, during , after , due to , clinical course , or temporally related to
should never be grouped with another relationship group; these attributes are "self-grouped". This means
w hen modeling concepts, a uthors place these attributes in a relationship group individually with no
other attributes .
Note: 726633004 | Temporally related to (attribute) | (http://snomed.info/id/726633004) only applies to
perioperative procedures and to a limited number of clinical findings.

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Figure 8: Stated view of a disorder hierarchy concept with Causative agent and Pathological process attribute-value
pairs in the same relationship group

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Situation with Explicit Context hierarchy

For 413350009 | Finding with explicit context (situation) | (http://snomed.info/id/413350009)concepts, the following four
attributes are grouped:
408729009 | Finding context (attribute) | (http://snomed.info/id/408729009)
246090004 | Associated finding (attribute) | (http://snomed.info/id/246090004)
408731000 | Temporal context (attribute) | (http://snomed.info/id/408731000)
408732007 | Subject relationship context (attribute) | (http://snomed.info/id/408732007)
For example, 704008007 | No family history of asthma (situation) | (http://snomed.info/id/704008007) IS A 243796009 |
Situation with explicit context (situation) | (http://snomed.info/id/243796009),
408729009 | Finding context (attribute) | (http://snomed.info/id/408729009), 410516002 | Known absent (qualifier
value) | (http://snomed.info/id/410516002)
246090004 | Associated finding (attribute) | (http://snomed.info/id/246090004) , 195967001 | Asthma (disorder) | (
http://snomed.info/id/195967001)

408731000 | Temporal context (attribute) | (http://snomed.info/id/408731000) , 410511007 | Current or past

(actual) (qualifier value) | (http://snomed.info/id/410511007)
408732007 | Subject relationship context (attribute) | (http://snomed.info/id/408732007), 444148008 | Person in
family of subject (person) | (http://snomed.info/id/444148008)
For 129125009 | Procedure with explicit context (situation) | (http://snomed.info/id/129125009)concepts the following
four attributes are grouped:
408730004 | Procedure context (attribute) | (http://snomed.info/id/408730004)
363589002 | Associated procedure (attribute) | (http://snomed.info/id/363589002)

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408731000 | Temporal context (attribute) | (http://snomed.info/id/408731000)

408732007 | Subject relationship context (attribute) | (http://snomed.info/id/408732007)
For example, 704503005 | Advice given about pelvic floor exercise (situation) | (http://snomed.info/id/704503005) IS A
129125009 | Procedure with explicit context (situation) | (http://snomed.info/id/129125009)
408730004 | Procedure context (attribute) | (http://snomed.info/id/408730004), 385658003 | Done (qualifier
value) | (http://snomed.info/id/385658003)
363589002 | Associated procedure (attribute) | (http://snomed.info/id/363589002), 420227002 |
Recommendation to (procedure) | (http://snomed.info/id/420227002)
408731000 | Temporal context (attribute) | (http://snomed.info/id/408731000), 410512000 | Current or specified
time (qualifier value) | (http://snomed.info/id/410512000)
408732007 | Subject relationship context (attribute) | (http://snomed.info/id/408732007), 125676002 | Person
(person) | (http://snomed.info/id/125676002)

Observable Entity hierarchy

When defining 363787002 | Observable entity (observable entity) | (http://snomed.info/id/363787002) concepts,
attribute-value pairs are self-grouped. Each observable entity represents only one property being observed.For
example, 400975005 | Standing diastolic blood pressure (observable entity) | (http://snomed.info/id/400975005) is
represented using multiple attributes with each in its own relationship group.

Figure 9: Stated view of a concept from the Observable entity hierarchy with self-grouped attributes

Domain Specific Modeling

SNOMED CT is arranged as a polyhierarchy. A hierarchy is defined as an ordered organization of concept codes
linked together through IS A relationships. Concept codes are linked to their more general parent concept codes
directly above them in a hierarchy. Concepts with more general meanings are usually located at the top of the
hierarchy and then at each level down the hierarchy the meanings become increasingly more specialized.
Selected SNOMED CT attributes have a hierarchical relationship to one another known as attribute hierarchies. In an
attribute hierarchy, one general attribute is the parent of one or more specific subtypes of that attribute. Concepts
defined using the more general attribute can inherit concepts modeled with the more specialized subtypes of that
attribute.
Domains

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The following are the 19 domains, arranged in alphabetical order. *Those without Concept Models are marked with
an asterisk.

HRCM Attribute tables

On the pages that follow, there are tables generated by the Human Readable Concept Model (HRCM).
They contain the Attribute Summaries for those domains with attributes, the information on Group(ed),
Cardinality, and In-group cardinality for each, and the Range constraints for each.
The HRCM tables only give ranges for pre-coordinated concepts. There may be post-coordination values
that are not included here.
For information on the definitions of Grouped, Cardinality, and In-group cardinality, please see: IHTSDO
Authoring Projects>Projects>MRCM Project>Process for the maintenance of MRCM rules

Modeling: precoordination patterns

SNOMED CT relies on the rules for usefulness to avoid excessive precoordination (see Does It Belong in
SNOMED CT?).
Approved precoordination patterns have been created and are available at: Pre-coordination Naming
Patterns JIRA Project. For additional information about the fields used in precoordination, see: What the
fields in the Pre-coordination Pattern JIRA Project mean.

Body Structure

Definition Examples

Includes Anatomical structures and Body structure

Morphologic abnormalities (subtype of
38033009 | Amputation stump (body structure) | (http://snomed.
body structure)
info/id/38033009)

91134007 | Mitral valve structure (body structure) | (http://snomed.

info/id/91134007)

Morphologic abnormality
189955008 | Biopsy wound (morphologic abnormality) | (
http://snomed.info/id/189955008)

31470003 | Adenosarcoma (morphologic abnormality) | (

http://snomed.info/id/31470003)

Cell
250293008 | Agranular white blood cell (cell) | (http://snomed.info
/id/250293008)

57184004 | T lymphocyte (cell) | (http://snomed.info/id/57184004)

Cell structure
4897009 | Cell membrane, prokaryotic (cell structure) | (
http://snomed.info/id/4897009)

362293000 | Entire axon (cell structure) | (http://snomed.info/id

/362293000)

The body structure domain includes anatomical structures, as well as morphologic abnormalities, as follows:
Body structure (body structure)
Anatomical or acquired body structure (body structure)

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Anatomical organizational pattern (body structure)

Anatomical site notations for tumor staging (body structure)
Body structure, altered from its original anatomical structure (morphologic abnormality)
Nonspecific site (body structure)
Normal anatomy (body structure)
Topography not assigned (body structure)
Topography unknown (body structure)

Tumor staging
Concepts under 258331007 | Anatomical site notations for tumor staging (body structure) | (http://snomed.
info/id/258331007) require review and reallocation.

Body Structure Attributes Summary

When authoring in this domain, these are the approved attributes and allowable ranges. They are from the Human
Readable Concept Model (HRCM). HRCM 2020-01-31

Domain Information for 123037004 | Body structure (body structure) | (http://snomed.info/id/123037004)

Domain Constraint << 123037004 | Body structure (body structure) | (http://snomed.info/id/123037004)

Parent Domain -

Proximal Primitive << 123037004 | Body structure (body structure) | (http://snomed.info/id/123037004)

Constraint

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 123037004 | Body structure (body structure) | (http://snomed.info/id
/123037004)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

733928003 | All or part of 0 0..* 0..0 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/733928003) /123037004)

733931002 | Constitutional part 0 0..* 0..0 << 123037004 | Body structure (body
of (attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/733931002) /123037004)

733933004 | Lateral half of 0 0..* 0..0 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/733933004) /123037004)

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774081006 | Proper part of 0 0..* 0..0 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/774081006) /123037004)

733930001 | Regional part of 0 0..* 0..0 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/733930001) /123037004)

733932009 | Systemic part of 0 0..* 0..0 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/733932009) /123037004)

HRCM 2020-01-31

Domain Information for 91723000 | Anatomical structure (body structure) | (http://snomed.info/id/91723000)

Domain Constraint << 91723000 | Anatomical structure (body structure) | (http://snomed.info/id/91723000)

Parent Domain 123037004 | Body structure (body structure) | (http://snomed.info/id/123037004)

Proximal Primitive << 91723000 | Anatomical structure (body structure) | (http://snomed.info/id/91723000)

Constraint

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 91723000 | Anatomical structure (body structure) | (http://snomed.info/id
/91723000)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

733928003 | All or part of 0 0..* 0..0 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/733928003) /123037004)

733931002 | Constitutional part 0 0..* 0..0 << 123037004 | Body structure (body
of (attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/733931002) /123037004)

733933004 | Lateral half of 0 0..* 0..0 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/733933004) /123037004)

272741003 | Laterality (attribute) | 0 0..1 0..0 << 182353008 | Side (qualifier value)
(http://snomed.info/id/272741003) | (http://snomed.info/id/182353008)

774081006 | Proper part of 0 0..* 0..0 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/774081006) /123037004)

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733930001 | Regional part of 0 0..* 0..0 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/733930001) /123037004)

733932009 | Systemic part of 0 0..* 0..0 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/733932009) /123037004)

Modeling: Laterality
For all Anatomical structure (body structure) concepts, Laterality is an approved attribute which can be
populated with the range of qualifier values including Side (qualifier value) or its subtypes.

Anatomical Structure Modeling

Many terms that refer to body systems or tracts are used imprecisely in clinical practice and in medical publications.
Ambiguities frequently arise with many of these terms. W e have made the following definitions and distinctions in
order to achieve internal consistency of the terminology. We recognize that it may not be possible to get universal
consensus for the names for each of these concepts. The goal is to be consistent and clear in defining the meaning
of each concept and to allow users and system designers to present the terms that best reflect these meanings in
their own implementations.
The Anatomical Concept Model can be found in Appendix B.

Section links
General anatomical concepts (see page )
Body parts, body regions (see page )
Surface regions (see page )
Abdominal regions (see page )
Abdominal cavity, pelvic cavity (see page )
Organs, organ system subdivisions (see page )
Cell, tissue, organ (see page )
Tree structured organs (see page )
Hollow tree organs (see page )
Cardiovascular system (see page )
Cardiac valves, normal and malformed (see page )
Systemic, pulmonary circulation (see page )
Arterial (see page )
Venous (see page )
Central, peripheral, cerebrovascular systems (see page )
Common carotid artery, artery of neck (see page )
Intracranial, extracranial vascular system (see page )
The word artery (see page )
The word vein (see page )
Trunk of vein, vein as a tree structure (see page )
Digestive system (see page )
Upper aerodigestive tract (see page )

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Biliary tract (see page )

Mouth (see page )
Tongue (see page )
Endocrine system (see page )
Genitourinary system (see page )
Urinary system/tract (see page )
Urinary tract proper (see page )
Lower urinary tract (see page )
Obstetric and gravid (see page )
Prostate lobes (see page )
Integumentary system (see page )
Skin, skin-associated mucosa (see page )
Skin regions, skin of <named body part> (see page )
Scalp (see page )
Soft tissue (see page )
Lymphatic, Immune, Hematologic, Hematopoietic systems (see page )
Lymphatic system (see page )
Lymphoid system (see page )
Immune system (see page )
Mononuclear phagocyte system (see page )
Dendritic cell system (see page )
Hematologic system (see page )
Hematopoietic system (see page )
Blood (see page )
Regional lymph nodes of lungs (see page )
Musculoskeletal system (see page )
Skeletal system, bony skeleton (see page )
Bone (see page 84)
Non-ossified bone (see page )
Bone marrow, bone cavity (see page )
Structure of (named bone), bone structure of (named bone) (see page )
Long bone, short bone (see page )
Sternum, manubrium, body, xiphoid (see page )
Teeth, maxilla, mandible (see page )
Joints, joint regions (see page )
Shoulder girdle (see page )
Intertarsal joint structure (see page )
Arm, leg and upper, lower extremities (see page )
Shoulder and hip regions, upper and lower limbs (see page )
Axilla (see page )
Tendon (see page )
Muscle function (see page )

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Nervous system (see page )

Nerve (see page )
Supratentorial brain (see page )
Respiratory system (see page )
Respiratory tract (see page )
Upper aerodigestive tract (see page )
Upper respiratory tract (see page )
Lower respiratory tract (see page )
Lower respiratory system (see page )
Interarytenoid fold or larynx (see page )
Nasal turbinates (see page )
Ear (see page )
Eye (see page )
Choroid (see page )
Retinal vein (see page )
Orbital region (see page )

General anatomical concepts

Body parts, body regions

SNOMED CT uses the Foundation Model of Anatomy (FMA) definition of body part and body part subdivision for
some concepts. For example, the joint regions discussed below are classified as body part subdivisions, since that is
what is intended by the diseases and procedures that use these terms in their definitions. They are not body parts
because they are defined, not by a set of bones, but rather by a particular joint and its surrounding structures.
However, our interpretation of the word region is based on common usage and is intended as a three-dimensional
structure, not the FMA two-dimensional definition of body region. In other words, these regions are not simply
surface regions (skin), but also include the three dimensional underlying structures (subcutaneous tissues, bones,
muscles, tendons, fascia, vessels and etc.).

Surface regions
Many concepts contain the phrase surface region. These could be interpreted as massless (immaterial)
mathematical surfaces, but a clinical terminology would have no direct use for such meanings in clinical records.
They could be interpreted as having mass (not immaterial), but the depth then is arbitrary. Should it be just skin
deep, or should it include deeper layers of the surface? If only skin deep, the meaning of these concepts would
overlap with concepts for skin regions. If deeper, the meaning would possibly be the same as the generic structure
concepts.

Inactivation
Most surface region concepts will be retired as ambiguous/possibly equivalent to their corresponding
concepts that are clearly not immaterial, including x structure, entire x, and skin of X. Where the x
structure codes do not currently exist, they will be created, without the surface region phrase.

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Abdominal regions
The named regions of the abdomen are by tradition divided horizontally by the transpyloric plane and the
interspinous plane, and vertically by the midclavicular plane. The lateral regions are therefore bounded above by a
plane that is inferior to the ribs. In contrast, the flank is the lateral region of the abdomen bounded above by the
ribs. Thus some parts of the hypochondriac regions, which are superior to the transpyloric plane but inferior to the
ribs, would be considered also part of the flank. The hypogastric region is also sometimes called the pubic region.

Abdominal cavity, pelvic cavity

The term abdominal cavity has two meanings, one including the pelvic cavity, the other excluding it. Abdominal
cavity structure includes both. Abdominal cavity proper excludes the pelvic cavity.

Organs, organ system subdivisions

The FMA definition of body organ is also used. Organs include individual bones, joints, muscles, arteries, veins,
lymph vessels, nerves, and etc. Concepts that include groups of organs are frequently used in SNOMED CT. In most
cases, these have been part of the subsumption hierarchy (IS A hierarchy) of the particular organ type, that is, they
are kinds of organs.
For concepts that refer to the collection of organs (rather than organs in a collection), there is another concept that
is a, kind of, organ system subdivision. Many such collections don't yet have corresponding organ system
subdivision concepts. The default is to interpret concepts as denoting organs, rather than organ system
subdivisions.

Collections of Organs with/without Organ System Subdivisions

Organ Organ system subdivision

Vertebra (bone of vertebral column) Spine (subdivision of skeletal system)

Cervical vertebra Cervical spine (subdivision of spine)

Third cervical vertebra No corresponding organ system subdivision concept

Bone of skull Skull (subdivision of skeletal system)

Bone of thoracic cage Thoracic cage (subdivision of skeletal system)

Rib No corresponding organ system subdivision concept

Third rib No corresponding organ system subdivision concept

Right third rib No corresponding organ system subdivision concept

Quadriceps femoris muscle No corresponding organ system subdivision concept

Quadriceps femoris muscle, left No corresponding organ system subdivision concept

Vastus medialis muscle No corresponding organ system subdivision concept

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Cell, tissue, organ

In general, organs are made up of tissue, and tissue is made up of cells. However, a cell is not necessarily part of
tissue, and tissue is not necessarily part of a named organ.

Tree structured organs

Arteries, veins, nerves, and the bronchi form tree-like structures that distribute across multiple regions. Because of
their size and links with other structures, they require slightly different modeling. FMA divides tree structured organs
as: organs with organ cavities and organs that are solid.

Hollow tree organs

Organ with organ cavity has a subtype, hollow tree organ. The hollow tree organs are:
Tracheobronchial
Biliary
Vascular
Arterial
Systemic arterial
Pulmonary arterial
Venous
Systemic venous (superior, inferior, and 4 cardiac trees)
Pulmonary venous (superior and inferior left and superior and inferior right)
Portal venous
Lymphatic (right lymphatic duct and thoracic duct)
Among the solid organs, there is one category, neural, that is tree-structured (see below: Nervous system; neural
tree).

Laterality, Digits
For information on laterality, see: 5. Laterality (draft)
See also 8. Naming convention for anatomy (draft) for information on naming concepts referring to digits

Combined site (body structure)

The concepts under 116007004 | Combined site (body structure) | (http://snomed.info/id/116007004) should
not be used for concept modeling. They do not provide value for the classification of disorders or
procedures. These concepts are ambiguous because their intended meaning is unclear, i.e. a combined
site could represent a ny part of two or more sites or all of the referred sites in the description. The
combined site (body structure) concepts will be inactivated.

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Body systems

Cardiovascular system

Cardiac valves, normal and malformed

There are a number of concepts in the anatomy hierarchy that represent congenital cardiac malformations. This
content was developed in cooperation with IPCCC (International Pediatric and Congenital Cardiac Code).
The following pairs of cardiac valve concepts do not represent the same thing and are siblings, not super- or
subtypes, to each other:
11124005 | Atrioventricular valve (body structure) | (http://snomed.info/id/11124005) vs. 279316009 |
Atrioventricular (non-mitral, non-tricuspid) valve structure (body structure) | (http://snomed.info/id/279316009)
91134007 | Mitral valve structure (body structure) | (http://snomed.info/id/91134007) vs. 312523009 | Left (non-
mitral) atrioventricular valve structure (body structure) | (http://snomed.info/id/312523009)
46030003 | Tricuspid valve structure (body structure) | (http://snomed.info/id/46030003) vs. 244344000 | Entire
right (non-tricuspid) atrioventricular valve (body structure) | (http://snomed.info/id/244344000)
Atrioventricular (non-mitral, non-tricuspid) valves represent body structures which were anatomically abnormal
from the beginning of their development. They are not called mitral/tricuspid valve although they perform the same
function as their normal counterpart would. They are also represented using the term not morphologically mitral
/tricuspid valve.
For example,
459176007 | Abscess of right atrioventricular (not morphologically tricuspid) valve (disorder) | (http://snomed.
info/id/459176007)represents an abscess of the right atrioventricular valve that has been developed abnormally
from the beginning vs. 431189009 | Abscess of tricuspid valve (disorder) | (http://snomed.info/id/431189009).
For a normally developed mitral/tricuspid valve, the term left/right atrioventricular valve can be used
interchangeably. They are true synonyms. However, they cannot be used for abnormally developed valves, i.e. left
atrioventricular (non-mitral)/right atrioventricular (non-tricuspid) valves.

Systemic, pulmonary circulation

The systemic circulatory system is the combined arterial and venous circulation that begins where blood leaves the
left ventricle and ends where blood enters the right atrium. It excludes the coronary circulation. The heart chambers
are also considered part of the circulatory system.
The pulmonary circulation is the combined arterial and venous circulation that begins where blood leaves the right
ventricle and ends where blood enters the left atrium.

Arterial
81040000 | Pulmonary artery structure (body structure) | (http://snomed.info/id/81040000): Any artery of the
pulmonary circulation, i.e. arteries carrying unoxygenated blood from the heart to the lungs. They include the trunk,
right and left branches of the pulmonary artery (which are within the mediastinum), and all of their branches (which
tend to occur at or past the hilum and are therefore regionally within the lung).
128260003 | Pulmonary artery within lung (body structure) | (http://snomed.info/id/128260003): Any artery of the
pulmonary circulation that is regionally within the lung, the boundary being defined by the hilum.
45341000 | Structure of trunk of pulmonary artery (body structure) | (http://snomed.info/id/45341000): The main
pulmonary artery (one of the great vessels that enter the heart) carrying blood from the right ventricle and dividing
into right and left main pulmonary arteries (some dictionaries consider this synonymous with pulmonary artery).

Venous
430757002 | Structure of pulmonary vein great vessel (body structure) | (http://snomed.info/id/430757002): There are
four pulmonary veins that enter the left atrium, two on each side. These are what is intended by the name |
pulmonary vein | (great vessels that enter the heart).

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In common usage, any vein that is part of the lung may be referred to as a pulmonary vein, but SNOMED CT has a
separate concept:
122972007 | Pulmonary venous structure (body structure) | (http://snomed.info/id/122972007): This means any vein
that drains the lung. A synonym is vein of lung. Pulmonary veins are vein of the lung, but pulmonary vein and vein
of lung are not synonyms.

No concept
There is no concept for pulmonary vein within lung.

Central, peripheral, cerebrovascular systems

The term central vascular is not in common use. In fact, the term does not appear in SNOMED CT. However, the
term peripheral vascular is very common, and therefore it requires a definition that (by default) sets the boundary
between central and peripheral vascular systems.
The simplest definition of the peripheral vascular system is the vascular system that is not central; and then the
central vascular system includes the pulmonary circulation, coronary circulation, cerebrovascular system, thoracic
aorta, superior vena cava, inferior vena cava, and mediastinal blood vessels.
Peripheral vascular disease is often distinguished from cerebrovascular disease and coronary artery disease. These
are the three major categories of diseases caused by problems in vascular circulation in general, and atherosclerosis,
in particular. As a result of this clinical distinction, the cerebrovascular system is excluded from the peripheral
vascular system.
Cerebrovascular is commonly defined in two ways: the blood vessels in the brain, or the blood vessels that supply
the brain (including those within the brain). Because cerebrovascular disease includes extra-cranial occlusions of the
vertebral and carotid arteries, we define the cerebrovascular system as those vessels involved in the supply and
drainage of blood to the brain. Convention does, however, tend to exclude the innominate artery - which gives rise
to the left common carotid and the arch of the aorta which gives rise to the right common carotid. Convention also
excludes the subclavian arteries which give rise to the vertebral arteries.

Common carotid artery, artery of neck

The common carotid artery has a left and right component. The right common carotid artery has no thoracic
portion (it arises from the brachiocephalic trunk behind the right sternoclavicular joint). The left common carotid
artery has a thoracic portion (It arises from the arch of the aorta). Thus, the common carotid artery (not specifiying
laterality) is not exclusively an artery of the neck. This is because of the thoracic portion of the left common carotid
artery. Then, artery of neck region includes the cervical part of left common carotid artery and all of the right
common carotid artery.

Intracranial, extracranial vascular system

Some vascular trees are located wholly within the cranial cavity, but some (internal carotid; vertebral) cross the
boundary between extra- and intra-cranial. Intracranial segments of such vascular trees must be individually
identified as such, and the entire vascular tree must not be categorized as either extra- or intra-cranial.

Tree-structured organs
See tree-structured organs above, re: regional sections of venous and arterial tree organs.

The word artery

The word artery has three different meanings. In modeling SNOMED CT concepts that refer to arteries, it is
necessary to decide on a case-by-case basis which of these meanings is intended.

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Meanings of artery

Meanings Notes Examples

An arterial trunk: a The most common in clinical use. A puncture wound of the femoral artery
single tube affects the femoral arterial trunk.
The meaning of the word artery in injuries
and operations is clearly a single tube, the A grafting into the popliteal artery is done
trunk of the named artery, or trunk of the into the popliteal arterial trunk.
named arterial branch.
Occlusions of arteries are located by
naming the trunk where the occlusion
occurs. Occlusions may affect circulation
beyond the trunk, however, collateral
circulation often mitigates the effects. Thus,
it is incorrect to interpret artery to mean the
entire subtree in any of these usages.

An arterial tree There are only two complete arterial tree NA

organ organs (the systemic arterial tree arising at
the aortic valve, and the pulmonary arterial
tree arising at the pulmonary valve) that are
readily named as such. They are seldom
referred to by disorders or procedures.

An arterial trunk, When modeling, it is challenging to NA

plus all its branches differentiate when trunk vs. trunk plus
branches is intended.

Artery
This clinical usage of artery varies from the definition of the FMA, which defines artery as a subdivision of
an arterial tree (organ) which consists of branching sets of tubes (arterial trunks) that form a tree;
together with other arterial trees (organ parts), it constitutes an arterial tree (organ). The FMA definition
corresponds to the third meaning of artery above.

The word vein

The word vein has three different meanings. In modeling SNOMED CT concepts that refer to veins, it is necessary to
decide on a case-by-case basis which of these meanings is intended.

Vein

Meaning Notes

A venous trunk As with the clinical usage of the word artery, clinical usage of the word vein
generally refers to the trunk and not the entire tree

A venous tree organ There are only eleven venous tree organs that are readily named as such.

A venous trunk, plus all its When modeling, it is challenging to differentiate when trunk vs. trunk plus
branches branches is intended.

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Vein
This clinical usage of vein varies from the definition of the FMA, which defines vein as a subdivision of a
venous tree (organ) which consists of branching sets of tubes (venous trunks) that form a tree; together
with other venous trees (organ parts), it constitutes a venous tree (organ). The FMA definition
corresponds to the third meaning of vein above.

Trunk of vein, vein as a tree structure

Because trunks of veins, not venous trees, have been used to organize the vein hierarchy, there are implications for
regional classes.
For example, the internal jugular vein is a vein of the neck, but its entire venous tree extends into the head. The
internal jugular vein venous tree is not strictly part of the neck, even though the internal jugular vein venous trunk is
strictly part of the neck.
Tributaries are also modeled as direct tributaries of the trunk. A tributary of a named vein is part of the venous tree
of the named vein, but not part of the venous trunk of the named vein. Some veins that are part of the venous tree,
and therefore might be regarded as indirect tributaries, are not modeled as direct tributaries of the trunk of the vein.
Direct tributary is the intended meaning of tributary.

Inactivation
All concepts with the name pattern vein x and its tributaries were inactivated due to ambiguity about
their meanings. They have MAYBE A links to structure of vein x and entire vein x.

Digestive system
Digestive tract is the same as alimentary tract, and includes the entire passage for food through the body, including
mouth, oral cavity (both vestibule of mouth and cavitas oris propria), oropharynx, esophagus, stomach, duodenum,
jejunum, ileum, colon, rectum, and anal canal.
Digestive system includes the digestive tract, as well as the associated organs of digestion, including tongue, teeth,
salivary glands, liver, exocrine pancreas, gallbladder, and biliary tract.
Gastrointestinal tract has two meanings in common usage. One that does and one that does not include the
esophagus. The usage that includes the esophagus would more correctly be named esophago-gastrointestinal tract.
Endoscopists frequently use this meaning, even though it is contrary to some dictionary definitions and does not
follow strict lexical interpretation (which does not include the esophagus).
Upper gastrointestinal (GI) tract. When describing upper GI bleeding and upper GI radiographic and endoscopic
procedures the upper GI tract includes the esophagus, stomach, and duodenum. The upper GI tract does not
include the more restricted stomach-intestine entity.
Lower gastrointestinal (GI) tract. When describing lower GI bleeding, lower GI radiographic and endoscopic
procedures, and lower GI output from ileostomies and colostomies, the lower GI tract includes the jejunum, ileum,
cecum, colon, rectum and anal canal. The ligament of Treitz may be used as the division between upper and lower
GI tracts (and the division between the duodenum and jejunum).
Also, since the upper GI tract is said to end at the duodenum-jejunum junction, and there is no concept meaning
middle GI tract, the jejunum can be inferred to be in the lower GI tract.

Information
See J Vasc Interv Radiol 9:747 for an example of inclusion of the jejunum and distal tract as part of the
lower GI tract.

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Upper aerodigestive tract; 119253004 | Upper aerodigestive tract structure (body structure) |
The SNOMED CT concept 361922007 | Entire upper aerodigestive tract (body structure) | (http://snomed.info/id
/361922007) has the meaning based on the following reference: Cancers of the upper aerodigestive tract constitute
approximately 4% of all malignancies. These include cancer of the lip, tongue, major salivary glands, gums and
adjacent oral cavity tissues, floor of the mouth, tonsils, oropharynx, nasopharynx, hypopharynx and other oral
regions, nasal cavity, accessory sinuses, middle ear, and larynx (Upper aerodigestive tract cancers, Cancer 1995 Jan 1;
75 (1 Suppl): 147-53). This definition matches the tumors included in the CAP Cancer Checklist for upper
aerodigestive tumors. The esophagus, or at least the cervical esophagus, may be included, but not in SNOMED CT.

Biliary tract
Biliary tract. Includes the gallbladder, intrahepatic and extrahepatic bile ducts, and common bile duct. It does not
include the liver. SNOMED CT uses biliary system as a synonym for biliary tract. SNOMED CT has another concept
that does include the liver, 732049009 | Entire liver and biliary system (body structure) | (http://snomed.info/id
/732049009).

Mouth
Mouth has several different meanings including mouth region, oral region of the face, and rima oris.
Mouth region. Includes structures surrounding the oral cavity, as well as structures of the oral region of the face.

Modeling
Use mouth region for most disorders with a finding site of mouth.

Oral region of face. Includes the skin and subcutaneous tissue of the lips and perioral region, the orbicularis oris
muscle, and the vessels and nerves in these structures.
Rima oris. The opening of the mouth.

Tongue
The four regional parts of the tongue are the ventrum (inferior surface), dorsum, root, and body. The root of the
tongue is the posterior third, the dorsal surface of which forms the anterior wall of the oropharynx. The root of the
tongue rests on the floor of the mouth. The nerves and vessels that supply the intrinsic muscles of the tongue
traverse the root of the tongue.

Endocrine system
The endocrine system is composed of the endocrine pancreas, pineal body, paraganglia, paraaortic bodies,
parathyroid glands, endocrine ovaries, endocrine testes, adrenal glands, pituitary gland, thyroid gland,
juxtaglomerular apparatus of the kidneys, and some diffuse neuroendocrine structures. Certain parts of the thymus
produce endocrine hormones, but the thymus itself is not part of the endocrine system.

Genitourinary system
The genitourinary system includes the entire urinary system, as well as the genital system. The genital system
includes internal genital organs and external genitalia.

Urinary system/tract
The urinary system includes the organs that form and excrete urine, the kidneys, ureters, bladder, and urethra. The
male urinary system includes the prostatic urethra (since it is a male urinary outflow structure).
In common usage, urinary system and urinary tract are used interchangeably. However, in SNOMED CT, this is not
they case, i.e. they are not synonyms. The two concepts are: 122489005 | Urinary system structure (body structure) |
(http://snomed.info/id/122489005) and 431938005 | Structure of urinary tract proper (body structure) | (http://snomed.info
/id/431938005).

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Urinary tract proper

The urinary tract proper includes the organs involved in the excretion of urine including the renal pelvis (but not the
rest of the kidney), ureters, bladder, and urethra. It is used for disorders affecting the flow of urine (as opposed to its
formation) or the urothelium, the lining of the urinary tract.
For example,
41368006 | Disorder of urinary tract proper (disorder) | (http://snomed.info/id/41368006)
249273002 | Finding of urinary tract proper (finding) | (http://snomed.info/id/249273002)
7163005 | Urinary tract obstruction (disorder) | (http://snomed.info/id/7163005)
255150000 | Carcinoma in situ of urinary tract proper (disorder) | (http://snomed.info/id/255150000)

Upper urinary tract

The upper urinary tract consists of the kidneys and the ureters (to the juncture with the bladder). Since upper
urinary tract infections include kidney infection, the upper urinary tract must include the kidney.

Upper urinary tract proper

The upper urinary tract proper is the part of the urinary tract proper. It includes only part of the kidney, the renal
pelvis, and the ureters.
For example,
25990002 | Renal pelvis structure (body structure) | (http://snomed.info/id/25990002) has a parent, 431491007 |
Structure of upper urinary tract proper (body structure) | (http://snomed.info/id/431491007).

Lower urinary tract

The lower urinary tract, 19787009 | Lower urinary tract structure (body structure) | (http://snomed.info/id/19787009), is
the urinary system below the junction of the ureter with the bladder. It consists of the bladder and urethra. Lower
urinary tract and lower urinary system are the same. The male and female specific components are located under
male urinary outflow structure and female urinary outflow structure, respectively.

Obstetric and gravid

Obstetric and gravid body structures should not be added in SNOMED CT. Obstetric is a context for a disorder,
procedure, or medical specialty that is applied to a body structure during pregnancy, childbirth, or the postpartum
period. The context does not change the body structure.

Prostate lobes
The posterior lobe of the prostate is described in newborns but does not persist in the adult. 113295002 | Structure
of lobe of prostate (body structure) | (http://snomed.info/id/113295002) includes three lobes, left and right lateral, and
medial.

Integumentary system

Skin, skin-associated mucosa

This is an example of a body structure that is used to group related terms. The concept 707861009 | Structure of
skin and/or skin-associated mucous membrane (body structure) | (http://snomed.info/id/707861009) intentionally
employs disjunction (inclusive Or). It includes structures in the deep layers, but excludes non-skin mucosal
epithelium, e.g. bronchial, gastrointestinal, and genitourinary sites of squamous cell neoplasms. The 400199006 |
Structure of skin and/or surface epithelium (body structure) | (http://snomed.info/id/400199006) concept is used to
represent the sites of these neoplasms.
Skin and/or skin-associated mucosa is intended for use in dermatology. It is not intended to subsume all mucosal
structures, which are under Mucous membrane structure (body structure).

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Diseases of the skin

For the meaning of diseases of the skin, refer to the draft of ICD-11: Diseases of the skin incorporate
conditions affecting the epidermis, its appendages (hair, hair follicle, sebaceous glands, apocrine sweat
gland apparatus, eccrine sweat gland apparatus and nails) and associated mucous membranes
(conjunctival, oral and genital), the dermis, the cutaneous vasculature and the subcutaneous tissue
(subcutis).

Skin regions, skin of <named body part>

Since the phrase skin of finger can mean some or all of the skin of finger (if interpreted as a structure, rather than
entire in the The StructureEntirePart (SEP) model, we could use IS-A to represent the relationship between skin of
finger and skin of hand. Thus, skin of finger IS-A skin of hand, IS-A Skin structure of upper extremity, IS-A skin region
. The word region is not used in all of these names, because it may refer to the entire region or a part of a region.

Scalp
Formal definitions of scalp include layers beneath the skin. Therefore we make a distinction between 41695006 |
Scalp structure (body structure) | (http://snomed.info/id/41695006) and 43067004 | Skin structure of scalp (body
structure) | (http://snomed.info/id/43067004).

Soft tissue
There are at least three different use cases and meanings, and thus categories, for the phrase soft tissue. They
include:
Tumors. Soft tissue gives rise to similar types of neoplasms of mesenchymal stem cell origin, generally called
soft tissue neoplasms. This accounts for the inclusions/exclusions of the category. Non-neoplastic masses
arising in soft tissue are included in the WHO Classification of Soft Tissue Tumours.
For tumors, soft tissue is defined as non-epithelial extraskeletal tissue of the body, exclusive of the
mononuclear phagocyte system, glia, and supporting tissue of various mesenchymal organs. Other
explicit inclusions are: fibrous tissue, fascia, ligaments, tendons, tendon sheaths, synovia, bursae,
skeletal muscle, smooth muscle, fatty tissue, adipose tissue, blood vessels, lymph vessels, peripheral
nerves, sympathetic and parasympathetic nerves, and ganglia, as well as subcutaneous tissue. Skin,
skeletal cartilage, pleura, and the pericardium, peritoneum, central nervous system, endocrine glands,
and viscera are excluded.
Sites of non-bone disorders and injuries of the limbs, head, neck, and body wall. Skeletal cartilage, as well as
all non-bone structures of the limbs, and subcutaneous tissue and fat are included. Skin and lymph nodes are
not included. For the head, neck and torso, mononuclear phagocyte system, central nervous system,
endocrine glands, viscera, and supporting tissues are excluded.
Structures identified in images. Soft tissue include everything except for mineralized bone tissue and teeth.

Lymphatic, Immune, Hematologic, Hematopoietic systems

Lymphatic system / 89890002 |Structure of lymphatic system (body structure)|

Set of structures through which lymph flows. It includes 59441001 | Structure of lymph node (body structure) | and
83555006 | Structure of lymphatic vessel (body structure) |. It supports the categorization of findings, disorders and
procedures that relate to the flow of lymph.

Lymphoid system / 122490001 |Lymphoid system structure (body structure)|

Set of structures with groups of lymphoid cells, including those in the intestines, marrow, liver, and other locations,
and the lymph nodes, spleen, thymus, and tonsils and adenoids; excludes the lymph vessels. It supports
categorization of lymphomas.

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Immune system/ 116003000 |Structure of immune system (body structure)|

All of the lymphoid system, as well as the mononuclear phagocytic system; the immune system also includes
cellular and sub-cellular components involved in cellular and humoral immunity.

Mononuclear phagocytic system / 127908000 |Mononuclear phagocyte system structure (body

structure)|
Collection of true macrophages, distributed widely in the body (splenic and lymphoid sinusoids, liver Kuppfer cells,
pulmonary alveolar macrophages, osteoclasts, macrophages in serous membranes, and microgliocytes); also
endothelial cells that line hematopoietic tissues.

Dendritic cell system / 127909008 |Dendritic cell system structure (body structure)|
Collection of antigen-presenting cells, including the following: epidermal Langerhans, dendritic reticulum, and
interdigitating. Class I histiocytoses (Langerhans cell histiocytosis) are disorders of the dendritic cell system.

Hematologic system / 414387006 |Structure of hematological system (body structure)|

Bone marrow, the lymphoid system, the hematopoietic system, and the terminal cells of all lineages of the
hematopoietic system (red cells, white cells, platelets, histiocytes, plasma cells, etc). Disorders of the hematologic
system do not necessarily include disorders of the hemostatic system, even though bleeding and thrombosis are
usually categorized as hematologic.

Hematopoietic system / 57171008 |Hematopoietic system structure (body structure)|

Structures and cells responsible for erythropoiesis, granulocytopoiesis, monocytopoiesis, thrombocytopoiesis, and
lymphopoiesis. Refers to the immature cellular elements that eventually form the cellular components of blood. The
blood itself cannot be strictly part of the hematopoietic system, since this would cause all components of blood to
be part of the hematopoietic system (including components like albumin, clearly not hematopoietic). SNOMED CT
considers leukocytes, erythrocytes, and platelets the result of hematopoiesis, but not blood-forming, otherwise
leukocytosis would become a disorder of hematopoiesis, whereas it can arise simply from a demargination of white
cells following stress. SNOMED CT has a concept named 419333002 | Cellular component of blood (substance) |;
note that platelets are not actually cells, but are cellular components.

Modeling
Hematopoietic should be differentiated from hematologic, since the terminal cells of each lineage (the
erythrocyte, segmented neutrophil, monocyte, histiocyte, platelet, mature T- and B-cells, plasma cells,
etc.) are not strictly hematopoietic.

Blood
The blood is not necessarily part of the cardiovascular system, nor is it necessarily part of the hematopoietic system.
87612001 | Blood (substance) | (http://snomed.info/id/87612001) is a body fluid, not strictly part of either the
hematopoietic or cardiovascular systems.

Regional lymph nodes of lungs

SNOMED CT has lymph node concepts per their anatomical locations, e.g. pulmonary, bronchopulmonary,
tracheobronchial, tracheal, and esophageal) and concepts for node groups used for clinical staging of lung cancer, i.
e. lymph nodes categorized into 14 stations.
Professional societies concerned with the clinical staging of lung cancer have developed at least three different
nomenclatures for stations of lung-related lymph nodes. Even though the numbering of the stations is very similar,
the inter-relationships between the various node groups are complex, particularly in stations 4 and 10, near the
carina and hilar regions.
SNOMED CT considers American Joint Committee on Cancer ( AJCC) Station 10, hilar lymph node, bronchial lymph
node, and bronchopulmonary lymph node as synonyms. The American Thoracic Society (ATS) Station 10R, the right
tracheobronchial lymph node is not a subtype of tracheobronchial lymph node because its definition includes

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nodes covered by both lower paratracheal lymph node, (AJCC Station 4) and by the hilar lymph node (AJCC Station
10). SNOMED CT uses tracheobronchial lymph node as a supertype of both inferior tracheobronchial (subcarinal)
and superior tracheobronchial (a subset of lower paratracheal).

Musculoskeletal system

Skeletal system, bony skeleton

The skeletal system (systema skeletal in Nomina Anatomica) includes bones and cartilage. The bony skeleton
includes bones only. The vertebral column is part of the skeletal system, and includes the intervertebral discs
(fibrocartilage). Individual vertebrae are part of the bony skeleton.

Skeletal system subdivision

SNOMED CT considers the skeletal system subdivision part of the entire bone (system). This may change
if there are procedures on cartilaginous skeleton that involve skeletal system subdivisions.

Bone
In ordinary usage, bone combines the meanings bone organ and bone tissue.
The 5 anatomical concepts related to bone are:

1. 3138006 | Bone (tissue) structure (body structure) | (http://snomed.info/id/3138006). Tissue type that makes up
bones; a quantity of regular connective tissue consisting of osteocytes and related cells, the intercellular
matrix of which is ossified; or any part thereof.
2. 90780006 | Entire bone (organ) (body structure) | (http://snomed.info/id/90780006). Individual bones, e.g. femur,
tibia, ulna, scaphoid, lunate. An organ with cavitated parts; consists primarily of compact (cortical) and
cancellous bone surrounding bone marrow cavities; also includes periosteum, endosteum (and, according to
FMA, articular cartilage).
3. 118966000 | Skeletal system subdivision (body structure) | (http://snomed.info/id/118966000). Groups of bones, e.
g. spine, skull, bony pelvis.
4. 128530007 | Entire bony skeleton (body structure) | (http://snomed.info/id/128530007). Pars ossea systematis
skeletalis, bone part of the skeletal system.
5. 113192009 | Skeletal system structure (body structure) | (http://snomed.info/id/113192009). Entire skeletal
system, including bones and cartilage.

Bone (tissue) is part of entire bone (organ); entire bone (organ) is part of skeletal system subdivision (system);
skeletal system subdivision (system) is part of entire bony skeleton (body structure); and entire bony skeleton (body
structure) is part of skeletal system structure (body structure). We can use Entire bone (system) to define aggregate
concepts that involve bones.

Modeling
FSNs for spinal levels should not contain abbreviations.
Correct example,
Posterior cord syndrome at tenth thoracic spinal cord level, not Posterior cord syndrome of
thoracic spinal cord at T10 level.

Non-ossified bone
Bone organs are composed primarily of bone tissue, but there are some non-ossified parts. In particular, periosteum
is clearly a part of a bone organ, but is not ossified tissue.

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Bone marrow, marrow cavity

Bone marrow is contained within the marrow cavity, but it is not part of the bone organ. The (empty) marrow cavity
is part of the bone organ. The bone marrow structure (body structure) is not a subtype of Bone structure (body
structure).
Clinically, marrow disorders are not usually considered bone disorders, nor are marrow procedures considered
bone procedures.
For example,
Bone marrow disorders are not musculoskeletal disorders, but bone disorders are musculoskeletal disorders.
Bone marrow transplants are not considered types of bone transplant.
60168000 | Osteomyelitis (disorder) | (http://snomed.info/id/60168000) is not the same as 44462005 | Osteitis
(disorder) | (http://snomed.info/id/44462005).

Structure of (named bone), bone structure of (named bone)

To differentiate marrow, vessels, nerves, and periosteum from the actual hard tissue of bones, we differentiate
structure of tibia from 12611008 | Bone structure of tibia (body structure) | (http://snomed.info/id/12611008). The bone
marrow and other soft tissues of the tibia can then be categorized separately from the hard tissues. Bone marrow
diseases are not considered musculoskeletal diseases, so bone marrow structures should not be placed in the bone
(tissue) structure hierarchy.

Long bone, short bone

ICD does not use the standard anatomical definition of long bone.
For example, Benign neoplasms of long bones are distinguished from benign neoplasms of short bones ; the bones
of the hand are considered short bones. The anatomical definition of long bone cites the proportional relationship
between length and width (length >> width). It is clear that metacarpals, metatarsals, and phalanges are included in
the anatomical definition of long bone.

Modeling: phalanx (finger)

The index finger is the first finger and second digit. Do not use second finger.

In order to accommodate the differences between anatomical definitions and classifications, SNOMED CT has
anatomical groupings that correspond to the ICD groupings. Scapula, humerus, radius, or ulna and long bone of
thigh or lower leg are used as the sites for grouper concepts that match ICD definitions and groupings.

Sternum, manubrium, body, xiphoid

The sternum is considered a bone organ. The manubrium, body, and xiphoid are parts of the sternum, classed as
zones in the FMA.

Teeth, maxilla, mandible

Even though teeth are supported by the maxillary or mandibular bone, they are not part of the 70925003 | Bone
structure of maxilla (body structure) | (http://snomed.info/id/70925003) or 91609006 | Bone structure of mandible (body
structure) | (http://snomed.info/id/91609006). Teeth are part of the 4335006 | Upper jaw region structure (body
structure) | (http://snomed.info/id/4335006) and 48077000 | Lower jaw region structure (body structure) | (http://snomed.
info/id/48077000).

Joints, joint regions

In many diseases and procedures, reference is made to areas of the body that may ambiguously imply either a joint
or a region surrounding the joint. Some common ones are:

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Joint vs. Joint Region

70258002 | Ankle joint structure (body structure) | ( 344001 | Ankle region structure (body structure) | (
http://snomed.info/id/70258002) http://snomed.info/id/344001)

74670003 | Wrist joint structure (body structure) | ( 8205005 | Wrist region structure (body structure) | (
http://snomed.info/id/74670003) http://snomed.info/id/8205005)

85537004 | Glenohumeral joint structure (body 16982005 | Shoulder region structure (body structure)
structure) | (http://snomed.info/id/85537004) | (http://snomed.info/id/16982005)

Shoulder girdle
272691005 | Bone structure of shoulder girdle (body structure) | (http://snomed.info/id/272691005). This concept is
used to define diseases and procedures affecting bones in the shoulder region, i.e. proximal humerus, scapula, and
clavicle. It is not a bone, but a bone structure, and is part of the shoulder region.

Intertarsal joint structure 27949001 |Intertarsal joint structure (body structure)|; SYN: Tarsal
joint
This structure is part of a group of bones forming the tarsus or tarsal joint (ankle). The 27162001 |
Talocalcaneonavicular joint structure (body structure) | (http://snomed.info/id/27162001) is the articulation between the
talus (one of the seven bones of the ankle joint) and the other bones of the tarsus, and is what is meant by the
rarely-used term talotarsal joint. The talocalcaneal joint is a synonym for the 127863007 | Subtalar joint structure
(body structure) | (http://snomed.info/id/127863007) . Dislocations of the subtalar joint usually involve the 127864001 |
Structure of talonavicular joint (body structure) | (http://snomed.info/id/127864001). The subtalar and talonavicular
joints constitute the talocalcaneonavicular joint.

Arm, leg and upper, lower extremities

The meaning of the words arm and leg may be misinterpreted.
Arm may refer to the upper limb, but it may also refer to the upper part of the arm.
Leg may refer to the lower limb, but it may also refer to the lower part of the leg. Stedman's Medical
Terminology defines lower leg as the segment of the inferior limb between the knee and the ankle.
In common usage, leg is a synonym of lower extremity, and arm is a synonym of upper extremity.
In SNOMED CT, 53120007 | Upper limb structure (body structure) | (http://snomed.info/id/53120007) includes the hand,
whereas 40983000 | Upper arm structure (body structure) | (http://snomed.info/id/40983000) does not; 61685007 |
Lower limb structure (body structure) | (http://snomed.info/id/61685007) includes the foot, whereas 30021000 | Lower
leg structure (body structure) | (http://snomed.info/id/30021000) does not.
NOTE: The word l imb appears in the FSN of the body structure, while the word extremity appears as a synonym.
Therefore, w hen constructing an FSN for a new clinical finding concept, this precedent should be followed:
FSN: 61685007 | Lower limb structure (body structure) | (http://snomed.info/id/61685007)
PT: Lower limb structure
Synonym: Lower extremity
Additional descriptions of leg and arm are permitted for concepts whose FSNs refer to lower limb and upper limb
respectively.

External sources

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External sources, such as WHO Classifications, may have conventions for interpreting the meaning of
phrases that contain the words arm and leg. These sources may be referenced to help determine the
meanings of International Classification of Diseases (ICD) terms when mapping or completing other
actions. ICD terms may differ from common usage and will not necessarily match SNOMED CT concepts.

Shoulder and hip regions, upper and lower limbs

The shoulder region is part of the upper limb, and the hip region is part of the lower limb. This follows the general
pattern used in the Foundation Model of Anatomy (FMA). The FMA defines the upper limb as the free upper limb and
the pectoral girdle (of which the shoulder region is part) and the lower limb as the free lower limb and pelvic girdle
(of which the hip region is part). SNOMED CT has the concept 699617006 | Structure of free lower limb (body
structure) | (http://snomed.info/id/699617006), i.e. the lower limb not including the pelvic girdle. There is not a concept
for the free upper limb.

Axilla
The axilla is bound by the upper limb laterally and the thorax medially. It may be viewed as not strictly part of the
upper limb or the thorax or it may be views as part of both. 91470000 | Axillary region structure (body structure) | (
http://snomed.info/id/91470000) is defined in SNOMED CT as being both an upper limb structure and a thoracic
structure.

Tendon
A muscle may be considered an entire functional unit, including attachments to the skeletal system, or merely the
contractile part of this unit. In clinical use, muscle is the contractile part only. The FMA definition implies that
tendons should be considered part of their corresponding muscles, rather than organs in their own right. SNOMED
CT models |Tendon structure| as a subtype of |Structure of muscle and/or tendon|. Muscle and tendon are two
separate anatomical entities.
For example, the 61352006 | Structure of achilles tendon (body structure) | (http://snomed.info/id/61352006) i s not a
53451005 | Triceps surae muscle structure (body structure) | (http://snomed.info/id/53451005) (gastrocnemius and/or
soleus) muscle structure.

Muscle function
When modeling muscle categories according to their functions, assume they mean the function of the entire muscle
, unless stated otherwise.

Nervous system
The nervous system has two parts, central and peripheral.
The central nervous system, sometimes also called the neuraxis, consists of the brain and spinal cord. The
pyramidal system is a subdivision of the central nervous system; the extrapyramidal system is part of the
brain.
The peripheral nervous system includes all neural structures outside the central nervous system.
The nervous system is also divided as: autonomic, somatic, and enteric.
The autonomic system is further divided as sympathetic and parasympathetic. The autonomic system is not
entirely a part of the peripheral nervous system, but the autonomic nerves are peripheral.

Nerve
The word nerve has multiple meanings according to the FMA:
nerve trunk
neural organ (trunk plus branches, excluding nuclei, ganglia, and roots)
neural tree organ, including nuclei, ganglia, roots, etc.

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A neural tree organ is defined in FMA as a nonparenchymatous organ which has as its parts an aggregate of
neurons (nuclei or ganglia) and their axons which are grouped into fasciculi by connective tissue to form elongated,
cable-like structures that are arranged into a tree. A nerve, according to FMA, is defined as a segment of a neural
tree organ which has as its parts a nerve trunk and its branches; together with other nerves of the same tree, it
constitutes a neural tree. The neural tree structure includes:
Cranial nerve
Complex cranial nerve-tract
Spinal nerve
Spinal accessory nerve (strictly neither cranial or spinal nerves)
Peripheral nerve
Autonomic nerve
Nerve, conventionally has two meanings:
An anatomically distinct nerve trunk (without branches) that is identified in a dissection (e.g. the structure
that student identifies when a pin is placed in the trunk of the vagus nerve, for instance located on the arch of
the aorta)
A larger anatomical entity which supports a related set of functions (e.g. all anatomical components of the
vagus nerve that are necessary for it to execute its functions (e.g. when a student is asked which nerve is
responsible for slowing the heart the answer, the vagus nerve, includes the vagal nucleus, as well as the trunk
and branches of the vagus).
Neural tree designates the second concept in order to distingiush it from the first which is only a part
(subdivision of) the vagal neural tree.
A third meaning of nerve, defined by the FMA is: Segment of neural tree organ which has as its parts a nerve trunk
and its branches; together with other nerves of the same tree it constitutes a neural tree .
For example,
Chorda tympani, digastric branch of facial nerve, greater petrosal nerve, posterior cutaneous branch of
posterior ramus of cervical nerve, superior lateral cutaneous nerve of arm.
If one severs the facial nerve, the meaning refers to the trunk. But if one has facial nerve palsy, the meaning
refers to the entire distribution of the nerve and the functions served by it.

Inactivation
There were several concepts with the phrase x nerve and its branches, interpreted as meaning the entire
nerve and its branches. Therefore, x nerve and its branches would be a duplicate of entire x nerve, when
we interpret entire x nerve as being a neural tree organ.
For example,
Entire facial nerve is a neural tree organ, so there is no need for an additional concept called facial
nerve and its branches.
Entire cranial nerve is a neural tree organ and structure of cranial nerve is that organ or any part
(or branch) thereof. Branches of the cranial and spinal nerves are segments of the neural tree
organs from which they branch.
All concepts named nerve x and its branches were inactivated due to their ambiguity. There are MAY BE A
links to structure of nerve x, and entire nerve x. Specifying trunk of a nerve requires a specific concept.

Supratentorial brain
Cerebrum may refer to the supratentorial brain, which is everything except the midbrain, medulla, pons, and
cerebellum. In this interpretation, the telencephalon and diencephalon are in the cerebrum. On the other hand,
cerebrum may only refer to the parts derived embryologically from the telencephalon, the cerebral hemispheres
and the intercerebral commissure (corpus callosum and anterior commissure).

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Supratentorial brain may be used for categorizing tumors and for designating the location of swelling that can result
in herniation. The telencephalon and diencephalon (including thalamus, geniculate bodies, pineal body, habenulae,
and hypothalamus) are definitely supratentorial. The upper part of the midbrain (mesencephalon) is also
supratentorial. SNOMED CT excludes all midbrain structures from the supratentorial brain.

Respiratory system

Respiratory tract; 321667001 |Respiratory tract structure (body structure)|

In SNOMED CT, respiratory tract has the same meaning as the Nomina Anatomica term apparatus respiratorius,
which includes the structures through which air passes from the nares to the alveoli. The oral cavity is not included.
In common usage, respiratory system may have the same meaning as respiratory tract; but not in SNOMED CT.
Respiratory system does not mean the global respiratory system that might include the CNS components of
breathing. Pleura are part of the lower respiratory system, but not a part of the lower respiratory tract.

Upper aerodigestive tract; 119253004 |Upper aerodigestive tract structure (body structure)|.
This phrase has several meanings. The SNOMED CT concept 361922007 | Entire upper aerodigestive tract (body
structure) | (http://snomed.info/id/361922007) has the meaning based on the following reference: Cancers of the upper
aerodigestive tract constitute approximately 4% of all malignancies. These include cancer of the lip, tongue, major
salivary glands, gums and adjacent oral cavity tissues, floor of the mouth, tonsils, oropharynx, nasopharynx,
hypopharynx and other oral regions, nasal cavity, accessory sinuses, middle ear, and larynx (Upper aerodigestive
tract cancers, Cancer 1995 Jan 1;75 (1 Suppl): 147-53). This definition matches the tumors included in the CAP
Cancer Checklist for upper aerodigestive tumors. The esophagus, or at least the cervical esophagus, may be
included, but not in SNOMED CT.

Upper respiratory tract; 58675001 |Upper respiratory tract structure (body structure)|
Includes the nasal cavity, paranasal sinuses, nasopharynx, oropharynx, and larynx

Lower respiratory tract; 82094008 |Lower respiratory tract structure (body structure)|
Includes the tracheobronchial tree (from the trachea through the terminal bronchioles) and the lungs, including the
alveolar respiratory tract (which extends from the respiratory bronchioles to the alveoli).

Lower respiratory system; 400141005 |Lower respiratory system structure (body structure)|
Includes the lower respiratory tract and the pleura.

Interarytenoid fold or larynx

The interarytenoid fold forms part of the inlet of the larynx. The fold has two surfaces, one forming part of the wall
of the supraglottic larynx, the other forming part of the wall of the hypopharynx (the food tube behind the larynx,
leading to the esophagus). The 102295003 | Structure of hypopharyngeal aspect of interarytenoid fold (body
structure) | (http://snomed.info/id/102295003) may be considered part of the hypopharynx, the larynx, or both. A tumor
of this site is categorized as a tumor of the hypopharynx, and not the larynx, but the 105585004 | Interarytenoid fold
structure (body structure) | (http://snomed.info/id/105585004) is considered part of the larynx.
SNOMED CT does not give a Part of relationship between the hypopharyngeal aspect of the interarytenoid fold and
the interarytenoid fold. This emphasizes SNOMED CT modeling based on the relationship of anatomical entities and
disorders and procedures and not simply by reading term names.

Nasal turbinates
SNOMED CT differentiates between the bone underlying the nasal turbinates and the actual turbinates:
Bones underlying the turbinates,
118648008 | Inferior nasal turbinate bone structure (body structure) | (http://snomed.info/id/118648008)
122491002 | Middle nasal turbinate bone structure (body structure) | (http://snomed.info/id/122491002)

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122492009 | Superior nasal turbinate bone structure (body structure) | (http://snomed.info/id/122492009)

122493004 | Supreme nasal turbinate bone structure (body structure) | (http://snomed.info/id/122493004)
Turbinates, which include bone, overlying mucous membranes, and other tissue,
6553002 | Inferior nasal turbinate structure (body structure) | (http://snomed.info/id/6553002)
122491002 | Middle nasal turbinate bone structure (body structure) | (http://snomed.info/id/122491002)
65289004 | Superior nasal turbinate structure (body structure) | (http://snomed.info/id/65289004)
33415007 | Supreme nasal turbinate structure (body structure) | (http://snomed.info/id/33415007)
The 118648008 | Inferior nasal turbinate bone structure (body structure) | (http://snomed.info/id/118648008) is a facial
bone and skull bone. And, parts of the ethmoid bone form the middle, superior, and supreme nasal conchae. This
means that the bones of the middle, superior, and supreme turbinates are not bone organs.

Ear
The ear includes the external, middle and inner ear. The external ear has two main parts, the auricle (also called the
pinna) and the 84301002 | External auditory canal structure (body structure) | (http://snomed.info/id/84301002). The
external auditory canal has the synonym external auditory meatus. The external auditory meatus is not just the
external opening of the canal, but rather the canal extending to the ear drum ( 42859004 | Tympanic membrane
structure (body structure) | (http://snomed.info/id/42859004)). The 61671002 | Structure of internal acoustic meatus of
temporal bone (body structure) | (http://snomed.info/id/61671002) (SYN, internal auditory canal, is not part of the ear.
As described in the FSN, it is an opening in the temporal bone, and is primarily a nerve conduit that anatomically
parallel to the external auditory canal.

Eye

Choroid
Both subchoroidal and suprachoroidal refer to the same potential anatomic space between the choroid and the
sclera. The term lamina subchoroidea of choroid is the same as the lamina suprachoroidea.

Suprachoroidal hemorrhage
In the literature, the term massive suprachoroidal hemorrhage is replacing expulsive hemorrhage and
subchoroidal hemorrhage.

Retinal vein
There is not a vein actually named retinal vein. However, SNOMED CT has concepts with the phrase.
For example,
85003000 | Structure of retinal vein (body structure) | (http://snomed.info/id/85003000) has the synonym retinal
vein.
280927000 | Entire central vein of the retina (body structure) | (http://snomed.info/id/280927000) has the
synonym entire central retinal vein.

Orbital region
371398005 | Eye region structure (body structure) | (http://snomed.info/id/371398005) has a synonym of orbital region
structure which subsumes bony orbit, entire eye, and ocular adnexa.

Unacceptable terms
X disorder at Y level concepts from ICD-11, e.g. skin laceration of arm at wrist level (precedent are terms
added from ICD-9) will not be added to the SNOMED International Release.

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(See also, Appendix, Concept Models: Anatomical Concept Model)

Morphologic Abnormality Modeling

The morphologic abnormality hierarchy is two levels below the body structure hierarchy, with siblings, apoptosis
and structure resulting from tissue repair process:
SNOMED CT concept
Body structure (body structure)
Body structure, altered from its original anatomical structure (morphologic abnormality)
Apoptosis (morphologic abnormality)
Morphologically abnormal structure (morphologic abnormality)
Structure resulting from tissue repair process (morphologic abnormality)
The concepts in the morphologic abnormality hierarchy represent abnormal body structures. The subhierarchy of
118956008 |Body structure, altered from its original anatomical structure (morphologic abnormality)| is to remain
primitive. Authors are not to define morphologic abnormality concepts.

Section links
Combined morphologies (see page )
Tumor morphology (see page )
Congenital anomaly (see page )
Degenerative abnormality, degeneration (see page )
Abscess (see page )
Fracture (see page )

Combined morphologies
When modeling a concept requiring two role groups with the same body structure but two different morphologies
(because a combined morphology does not exist), then those morphologic abnormalities can be combined to
create a single |(morphologic abnormality)| concept.

Combined morphology
It is inappropriate to add more than two morphological concepts into a single concept, i.e. combining 2
morphological concepts which already represent a combined concept is not permitted.

Keep the newly created morphologic abnormality concept primitive as all morphologic abnormality concepts
should be primitive.
For example,
If 400067002 | Acantholytic epidermal nevus (disorder) | (http://snomed.info/id/400067002) had the same finding site of
|Skin structure| with two different morphologic abnormalities of |Epidermal nevus (morphologic abnormality)| and
|Acantholysis (morphologic abnormality)|, then those two morphologic abnormality concepts can be combined to
create a single, primitive, morphologic abnormality concept of |Acantholytic epidermal nevus (morphologic
abnormality)|. This will prevent modeling with two relationship groups.
Instead of modeling as per this diagram in the stated view with two morphologies of the same finding site:

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Model as in the stated view of this diagram with a combined morphology:

Tumor morphology
SNOMED CT accepts tumor concepts, as long as they are included in the International Classification of Diseases for
Oncology (ICD-O). ICD-O has two coding systems for coding the site (topography) and the histology (morphology)
of the neoplasm:
Topographical - Anatomical site of origin or the organ system
Morphological - Tumor cell type or histology and behavior, i.e. malignant versus benign
The topography code describes the site of origin of the neoplasms; The morphology code describes the cell type of
the tumor and its biologic activity, in other words, the characteristics of the tumor itself.The morphology code,
combined with the appropriate topography, expresses the complete morphological assessment as stated by the
pathologist.

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Specifically, there are histology types that refer to an organ by means of reference to the architecture, that is the
particular histology. For example, Lymphoepithelioma-like carcinoma as enumerated by CAP (and ICD-O). The
topographical reference is made to a morphology that is similar to, but distinct from, lymphoepthlium.
SCT intends to avoid adding concepts that conflate the localization of a specific tumor type in a topographic
location as opposed to a neoplastic cell type that is derived from a specialized cell in an organ. E.g. Adenocarcinoma
vs. renal clear cell carcinoma. One is general, the other specific to a cell type.

Exception
Some ICD-O codes include Not Otherwise Specified (NOS). These concepts are not acceptable in
SNOMED CT.

For more information

ICD-O @ http://www.iacr.com.fr (http://www.iacr.com.fr/index.php?
option=com_content&view=category&layout=blog&id=100&Itemid=577).

Congenital anomaly
Disorders which involve congenital anomalies are defined with Occurrence (attribute) = Congenital (qualifier value),
Associated morphology (attribute) = Morphologic abnormality (qualifier value) and Pathological process (attribute) =
Pathological development process (qualifier value).
Therefore, congenital does not need to be represented as the Associated morphology (attribute) target value.
Congenital anomaly morphology concepts usually have non-congenital parents.

Degenerative abnormality, degeneration

A distinction should be made between 107669003 | Degenerative abnormality (morphologic abnormality) | (
http://snomed.info/id/107669003) and 33359002 | Degeneration (morphologic abnormality) | (http://snomed.info/id
/33359002).

33359002 | Degeneration (morphologic abnormality) | (http://snomed.info/id/33359002) is a child of 107669003 |

Degenerative abnormality (morphologic abnormality) | (http://snomed.info/id/107669003).
107669003 | Degenerative abnormality (morphologic abnormality) | (http://snomed.info/id/107669003) is a
grouper concept with members usually characterized by retrogressive pathologic structural changes.
Diseases that are degenerative do not necessarily have 116676008 | Associated morphology (attribute) | (
http://snomed.info/id/116676008) of 33359002 | Degeneration (morphologic abnormality) | (http://snomed.info/id
/33359002), since the word degenerative sometimes refers to loss of function rather than structural
degeneration.
Examples include degeneration proper, as well as lysis, vascular sclerosis, necrosis, infarct, deposition, dystrophy,
pigmentation, atrophy, and depletion.
Morphologies under degeneration also have retrogressive structural changes, but they are not necessarily any
of the above, nor are they necessarily resorption, malacia, obliteration, opacity, plaque, or postmortem
change (this seems to be definition by exclusion).
Necrosis is a degenerative abnormality, but not a degeneration. Necrosis can follow degeneration.
Atrophy is a degenerative abnormality, but only atrophic degeneration is also a degeneration.

Modeling
33359002 | Degeneration (morphologic abnormality) | (http://snomed.info/id/33359002) and 107669003 |
Degenerative abnormality (morphologic abnormality) | (http://snomed.info/id/107669003) should rarely, if
ever, be used as the value of Associated morphology of a particular disorder; rather, a more specific
subtype should be used.

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Exception
It might be used as the value of Associated morphology for a broad category of degenerative disorders
when the degeneration is always and necessarily structural. It is then inherited by all the subtypes, unless
specialized by assigning a subtype of degeneration as the value for Associated morphology.

Abscess
There are two types of abscesses: septic and sterile. Most abscesses are septic, which means that they are the result
of an infection. If a concept has a meaning (based on its FSN and text definition) that does not specify whether the
abscess is sterile or septic, then the concept should not be modeled as septic; the concept's logic definition uses
116676008 | Associated morphology (attribute) | (http://snomed.info/id/116676008) with the value 44132006 | Abscess
(morphologic abnormality) | (http://snomed.info/id/44132006).

Fracture
Although most fractures are traumatic, there are some pathological fractures. In the vast majority of cases, fractures
are traumatic. Based on its FSN and text definition, if the word pathological is present, use Pathologic fracture
(morphologic abnormality).

Example: Modeling Traumatic vs. Pathological Fractures

Concept Finding Site Associated

Morphology

21351003 | Fracture of phalanx of foot (disorder) | ( Bone structure of phalanx of Fracture

http://snomed.info/id/21351003) foot

704168008 | Pathological fracture of phalanx of foot Bone structure of phalanx of Pathologic fracture
(disorder) | (http://snomed.info/id/704168008) foot

1076491000119102 | Nontraumatic complete rupture of muscle or tendon structure of rotator cuff of left shoulder
(disorder) | (http://snomed.info/id/1076491000119102)

Morphologic Abnormalities vs. Findings

Concepts from the Morphologic Abnormality hierarchy should not be used in place of concepts from the Clinical
Findings hierarchy, even though they appear to refer to similar clinical situations.
For example,
4147007 | Mass (morphologic abnormality) | (http://snomed.info/id/4147007) is not a finding, but 300848003 |
Mass of body structure (finding) | (http://snomed.info/id/300848003) is a finding
Morphologies are used as the values of the defining attributes of findings and procedures. Findings are used to
represent the combination of a morphology and a location.
For example,
300923002 | Cyst of scalp (disorder) | (http://snomed.info/id/300923002) represents cystic type of morphology
that has the location, scalp
Many morphologies have names that could be misinterpreted as implying a process rather than a structure.
Inflammation might mean the structural-morphologic features of inflammation, such as inflammatory cell
infiltrates; or it might mean the process that causes the structural changes. Within the morphologic
abnormality hierarchy, the structural interpretation is intended, not the process interpretation.

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Clinical Finding/Disorder

Definition Examples

Clinical finding: normal/abnormal observations, judgments, Clinical finding

or assessments of patients
167222005 | Abnormal urinalysis
Disorder: always and necessarily an abnormal clinical state (finding) | (http://snomed.info/id
/167222005)

Disorder
39579001 | Anaphylaxis (disorder) | (
http://snomed.info/id/39579001)

Clinical findings or observations are the active acquisition of subjective or objective information from a primary
source. This includes information acquired from human observers, through recording of data via the use of
scientific instruments or indirectly from samples taken from the source and evaluated separately.

Observations
The term "observations ” should not be confused with "Observable entity ”, i.e. the name of something
that can be observed and represents a question or assessment which can produce an answer or result (e.
g. | systolic blood pressure|, |color of iris|, |gender|.

Context
The default context for a Clinical finding concept is:
Present (vs. being absent)
Subject of the record (the patient)
Current, if not specifically stated or specified to a time in the past by an entity linked to the
concept

The Clinical finding hierarchy contains the sub-hierarchy of Disorder. Concepts that are descendants of disease
(disorder) are always and necessarily abnormal clinical states.
This subtype allows diseases to be subtypes of other disorders, as well as subtypes of findings.
C oncepts with a semantic tag of disorder, must have a parent of Disease (disorder) and not Clinical finding (finding)
.
For example,
95617006 | Neonatal cyanosis (disorder) | (http://snomed.info/id/95617006) has the parent, Disease (disorder); it is
a subtype of 3415004 | Cyanosis (finding) | (http://snomed.info/id/3415004).
The distinction between a disorder and a finding may be difficult to define. There are, however, distinct
characteristics of each.

Disorder vs Finding

Characteristics

Disorder Always and necessarily abnormal

Necessarily have an underlying pathological process

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Disorder vs Finding

Have temporal persistence (may be under treatment, in remission, or inactive, even though
they are still present)
May be present as a propensity for certain abnormal states to occur, even when treatment
mitigates or resolves those abnormal states

Finding May be normal (but not necessarily)

May exist only at a single point in time (e.g. a serum sodium level)
Cannot be temporally separate from the observation (one cannot observe them and say they
are absent, nor can they be present when they cannot be observed)
Cannot be defined only in terms of an underlying pathological process that is present, when
the observation itself is not present

In some cases the disease process is irrefutable, e.g. meningococcal meningitis. In others an underlying disease
process is assumed based on the temporal and causal association of the disorder and its manifestation, e.g.
nystagmus (disorder) is different from nystagmus present (finding). Nystagmus present (finding) may be a normal
physiological response to head rotation. A person who spins around and has nystagmus present (finding), does not
have nystagmus (disorder). Alternatively, a person may have nystagmus (disorder), but not nystagmus present
(finding), i.e they do not currently manifest nystagmus. Similarly, hearing loss (disorder) is different from perception
of hearing loss (finding), which can be due to a number of temporary causes, such as excessive ear wax.

Clinical Finding Attributes Summary

When authoring in this domain, these are the approved attributes and allowable ranges. They are from the Human
Readable Concept Model (HRCM). HRCM 2020-01-31

Domain Information for 404684003 | Clinical finding (finding) | (http://snomed.info/id/404684003)

Domain Constraint << 404684003 | Clinical finding (finding) | (http://snomed.info/id/404684003)

Parent Domain -

Proximal Primitive << 404684003 | Clinical finding (finding) | (http://snomed.info/id/404684003)

Constraint

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 404684003 | Clinical finding (finding) | (http://snomed.info/id/404684003)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

255234002 | After (attribute) | ( 1 0..* 0..1 << 404684003 | Clinical finding

http://snomed.info/id/255234002) (finding) | (http://snomed.info/id
/404684003) OR

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<< 71388002 | Procedure (procedure)

| (http://snomed.info/id/71388002) OR
<< 272379006 | Event (event) | (
http://snomed.info/id/272379006)

116676008 | Associated 1 0..* [New]0..1 << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/116676008) abnormality) | (http://snomed.info/id
1 0..* 0..* /49755003)

47429007 | Associated with 1 0..* 0..* << 404684003 | Clinical finding

(attribute) | (http://snomed.info/id (finding) | (http://snomed.info/id
/47429007) /404684003) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002) OR
<< 272379006 | Event (event) | (
http://snomed.info/id/272379006) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR
<< 105590001 | Substance (substance)
| (http://snomed.info/id/105590001) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 78621006 | Physical force (physical
force) | (http://snomed.info/id/78621006)

288556008 | Before (attribute) | ( 1 0..* 0..1 << 71388002 | Procedure (procedure)

http://snomed.info/id/288556008) | (http://snomed.info/id/71388002)

246075003 | Causative agent 1 0..* 0..1 << 410607006 | Organism (organism)

(attribute) | (http://snomed.info/id | (http://snomed.info/id/410607006) OR
/246075003) << 105590001 | Substance (substance)
| (http://snomed.info/id/105590001) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 78621006 | Physical force (physical
force) | (http://snomed.info/id/78621006)

263502005 | Clinical course 1 0..* 0..1 << 288524001 | Courses (qualifier

(attribute) | (http://snomed.info/id value) | (http://snomed.info/id/288524001)
/263502005)

42752001 | Due to (attribute) | ( 1 0..* 0..1 << 404684003 | Clinical finding

http://snomed.info/id/42752001) (finding) | (http://snomed.info/id
/404684003) OR
<< 272379006 | Event (event) | (
http://snomed.info/id/272379006) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002)

371881003 | During (attribute) | ( 1 0..* 0..1 << 71388002 | Procedure (procedure)

http://snomed.info/id/371881003) | (http://snomed.info/id/71388002)

1 0..* 0..1 << 288526004 | Episodicities (qualifier

value) | (http://snomed.info/id/288526004)

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246456000 | Episodicity
(attribute) | (http://snomed.info/id
/246456000)

419066007 | Finding informer 1 0..* 0..1 << 420158005 | Performer of method

(attribute) | (http://snomed.info/id (person) | (http://snomed.info/id
/419066007) /420158005) OR
<< 419358007 | Subject of record or
other provider of history (person) | (
http://snomed.info/id/419358007) OR
<< 444018008 | Person with
characteristic related to subject of
record (person) | (http://snomed.info/id
/444018008)

418775008 | Finding method 1 0..* 0..1 << 71388002 | Procedure (procedure)

(attribute) | (http://snomed.info/id | (http://snomed.info/id/71388002)
/418775008)

363698007 | Finding site 1 0..* [New]0..1 << 442083009 | Anatomical or

(attribute) | (http://snomed.info/id acquired body structure (body
/363698007) structure) | (http://snomed.info/id
1 0..* 0..* /442083009)

363713009 | Has interpretation 1 0..* 0..1 << 260245000 | Finding values

(attribute) | (http://snomed.info/id (qualifier value) | (http://snomed.info/id
/363713009) /260245000) OR
<< 263714004 | Colors (qualifier value)
| (http://snomed.info/id/263714004)

719722006 | Has realization 1 0..* 0..1 << 719982003 | Process (qualifier

(attribute) | (http://snomed.info/id value) | (http://snomed.info/id/719982003)
/719722006)

363714003 | Interprets 1 0..* 0..1 << 363787002 | Observable entity

(attribute) | (http://snomed.info/id (observable entity) | (http://snomed.info
/363714003) /id/363787002) OR
<< 108252007 | Laboratory procedure
(procedure) | (http://snomed.info/id
/108252007) OR
<< 386053000 | Evaluation procedure
(procedure) | (http://snomed.info/id
/386053000)

246454002 | Occurrence 1 0..* 0..1 << 282032007 | Periods of life

(attribute) | (http://snomed.info/id (qualifier value) | (http://snomed.info/id
/246454002) /282032007)

370135005 | Pathological 1 0..* 0..1 << 769247005 | Abnormal immune

process (attribute) | ( process (qualifier value) | (
http://snomed.info/id/370135005) http://snomed.info/id/769247005) OR
<< 441862004 | Infectious process
(qualifier value) | (http://snomed.info/id
/441862004) OR
<< 472963003 | Hypersensitivity
process (qualifier value) | (

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http://snomed.info/id/472963003) OR
<< 308490002 | Pathological
developmental process (qualifier
value) | (http://snomed.info/id/308490002)

246112005 | Severity (attribute) 1 0..* 0..1 << 272141005 | Severities (qualifier

| (http://snomed.info/id/246112005) value) | (http://snomed.info/id/272141005)

726633004 | Temporally related 1 0..* 0..* << 404684003 | Clinical finding

to (attribute) | (http://snomed.info (finding) | (http://snomed.info/id
/id/726633004) /404684003) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002)

Clinical Finding Defining Attributes

Relationship group clarification

The attributes before, during , after , due to , clinical course , or temporally related to must not be placed
in a relationship group with other attributes. Each attribute must be the only attribute in the relationship
group.
The Human Readable Concept Model (HRCM) groupedproperty correctly indicates that these attributes
are put into a relationship group during classification (see the Clinical Finding Attributes Summary table
on the previous page).

The following defining attributes correspond to the Clinical Finding/Disorder Attributes Summary table.

After
This attribute is used to model concepts in which a clinical finding occurs after another clinical finding, procedure
or event. Neither asserting nor excluding a causal relationship, it instead emphasizes a sequence of events.
For example,
123948009 | Post-viral disorder (disorder) | (http://snomed.info/id/123948009) occurs | After (attribute) | (
http://snomed.org/fictid#) 34014006 | Viral disease (disorder) | (http://snomed.info/id/34014006)

A clinical finding may start either: after a variable period of time; immediately following the resolution of its
antecedent; or during the course of its antecedent but continue after the antecedent has resolved. These sequences
correspond to Allen's interval algebra relations of:
X takes place before Y
X meets Y
X overlaps with Y

Associated morphology
This attribute specifies the morphologic changes seen at the tissue or cellular level that are characteristic of a
disease.
(Please see Morphologic Abnormalities vs. Findings for details).
For example,
75694006 | Pancreatitis (disorder) | (http://snomed.info/id/75694006) has the Associated morphology of
409774005 | Inflammatory morphology (morphologic abnormality) | (http://snomed.info/id/409774005)

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When selecting a value for this attribute, in general, the concept should not represent a body structure combined
with the morphology. There are, however, exceptions, i.e. where a morphology implies the finding site.
For example,
444231005 | Thymoma (disorder) | (http://snomed.info/id/444231005)
80400009 | External hyperostosis (morphologic abnormality) | (http://snomed.info/id/80400009)

Body structure should be captured in the value selected for the Finding site attribute. There are, however,
exceptions.
For example,
70529004 | Lymphoid hyperplasia of appendix (disorder) | (http://snomed.info/id/70529004) has | Associated
morphology (attribute) | (http://snomed.org/fictid#) of 43961000 | Lymphoid hyperplasia (morphologic
abnormality) | (http://snomed.info/id/43961000) and a | Finding site (attribute) | (http://snomed.org/fictid#) of
45679000 | Appendiceal lymphoid nodule (body structure) | (http://snomed.info/id/45679000)

Figure 1: Stated view of Lymphoid hyperplasia of appendix (disorder)

Associated with
47429007 | Associated with (attribute) | (http://snomed.info/id/47429007) represents a clinically relevant association
between concepts without either asserting or excluding a causal or sequential relationship between the two.
In general, avoid using the 47429007 | Associated with (attribute) | (http://snomed.info/id/47429007). It may be
ambiguous and difficult to apply consistently.
Exceptions include,
Device infections, i.e an infection of the tissue surrounding an implanted or inserted device, not due to the
device itself.
47429007 | Associated with (attribute) | (http://snomed.info/id/47429007) is used to associate the device
with the infection.
Intolerance to substances, i.e the propensity of an adverse reaction to a substance to occur (other than
hypersensitivity or allergic or non-allergic hypersensitivity). There is no intolerance process that serves as the
value for 719722006 | Has realization (attribute) | (http://snomed.info/id/719722006).
47429007 | Associated with (attribute) | (http://snomed.info/id/47429007) is used to associate the
intolerance to the substance.
This attribute may be appropriate when creating concepts that group specific associations.
For example,
6211002 | Polyarthritis associated with another disorder (disorder) | (http://snomed.info/id/6211002)

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Figure 2: Inferred view of concept using the |Associated with (attribute)|

Before
This attribute is used to model pre-procedure complications (e.g, preoperative complication) . It represents temporal
associations between procedures and related disorders.

Causative agent
This attribute identifies an organism, substance, physical object, physical force, and/or pharmaceutical/biological
product as the direct cause of a condition. It does not include vectors, for example, a mosquito that transmits
malaria.
For example,
4989003 | Electrical burn of skin (disorder) | (http://snomed.info/id/4989003) has the 246075003 | Causative
agent (attribute) | (http://snomed.info/id/246075003) of 18213006 | Electricity (physical force) | (http://snomed.info
/id/18213006)

Clinical course
This attribute is used to represent both the course and onset of a disease or condition.
The clinical course value is added when appropriate to the condition and thus specified in the FSN. The distinction
is often necessary in those conditions that can have either an acute or a chronic course, such as bronchitis. For
those conditions that have only one clinical course, i.e. diabetes is a chronic disease, a wider discussion is necessary
before a decision can be made whether to assign a clinical course. Decisions on these concepts are currently made
on a case-by-case basis.
Many conditions with acute (sudden) onsets also have acute (short-term) courses. However, few conditions with
chronic (long-term) durations require rapid vs. gradual onset subtyping. Thus, there is no clear need for separating
the rapidity of onset from the duration of a disease. This attribute, that combines onset and course, has been more
reproducible and useful than two attributes that attempt to separate the meanings.
For example,
74973004 | Chronic fibrosing pancreatitis (disorder) | (http://snomed.info/id/74973004) has a 263502005 | Clinical
course (attribute) | (http://snomed.info/id/263502005) of 90734009 | Chronic (qualifier value) | (http://snomed.info/id
/90734009)

The word - acute

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The word acute has more than one meaning, and the meanings are often overlapping or unclear. It may
imply rapid onset, short duration, or high severity; in some circumstances it might be used to mean all of
these. For morphological concepts, acute may also imply the kind of morphology associated with the
speed of onset.
For example,
4532008 | Acute inflammation (morphologic abnormality) | (http://snomed.info/id/4532008) does not
necessarily have a clinical course of sudden onset and/or short duration, but rather implies
polymorphonuclear infiltration ( 84499006 | Chronic inflammation (morphologic abnormality) | (
http://snomed.info/id/84499006) implies mononuclear cell infiltration, not necessarily a chronic
course, although inflammation with a chronic course is highly correlated with a lymphocytic
infiltration)

Normally, 263502005 | Clinical course (attribute) | (http://snomed.info/id/263502005) is not grouped with other
attributes. However, an exception to this rule exists with the 719722006 | Has realization (attribute) | (http://snomed.
info/id/719722006). Role grouping the clinical course is exclusive to the | Has realization (attribute) | (http://snomed.org
/fictid#) when the clinical course describes the realization and not the entire concept itself.

For example,
788781001 | Delayed allergy to red meat (finding) | (http://snomed.info/id/788781001) groups 263502005 |
Clinical course (attribute) | (http://snomed.info/id/263502005) of 788800008 | Delayed onset (qualifier value) | (
http://snomed.info/id/788800008) with 719722006 | Has realization (attribute) | (http://snomed.info/id/719722006) of
769260004 | Immunoglobulin E-mediated allergic process (qualifier value) | (http://snomed.info/id/769260004).
Each is contained in a separate role group with a causative agent of either 226915003 | Red meat (substance)
| (http://snomed.info/id/226915003) or 788778006 | Galactose-alpha-1,3 galactose (substance) | (http://snomed.info
/id/788778006). A tick bite causes the 788779003 | Allergy to galactose-alpha-1,3 galactose (finding) | (
http://snomed.info/id/788779003), which in turn causes the 788781001 | Delayed allergy to red meat (finding) | (
http://snomed.info/id/788781001).

Due to
This attribute is used to identify a clinical finding/disorder, event, or procedure concept as the direct cause of
another Clinical finding or Disorder concept. (If the clinical finding merely predisposes to or worsens another
disorder, rather than causing it directly, the more general | Associated with (attribute) | (http://snomed.org/fictid#) is
used instead).
For example,
43959009 | Cataract of eye due to diabetes mellitus (disorder) | (http://snomed.info/id/43959009)

During
This attribute is used to model concepts in which a clinical finding occurs during a procedure. Neither asserting nor
excluding a causal relationship, it instead emphasizes a sequence of events.
For example,
10901000087102 | Hypotension during surgery (disorder) | (http://snomed.info/id/10901000087102) has the value
Surgical procedure (procedure) for During (attribute)

Episodicity
This attribute is used to represent episodes of care provided by a physician or other healthcare provider, not
episodes of disease experienced by the patient.
For example,
Asthma with 246456000 | Episodicity (attribute) | (http://snomed.info/id/246456000) of 255217005 | First episode
(qualifier value) | (http://snomed.info/id/255217005) represents the first time the patient presents to their
healthcare provider with asthma.

Modeling

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Episodicity is not used to model any concepts precoordinated in the International Release, but it can be
used as a qualifier in postcoordination.

Finding informer
This attribute specifies the person or other entity from which the clinical finding information was obtained. It is not
about the particular individual but about the category or type of informer. It is used to differentiate patient-reported
symptoms from provider-determined signs. This attribute is frequently used in conjunction with 418775008 |
Finding method (attribute) | (http://snomed.info/id/418775008).

Finding method
This attribute specifies the means by which a clinical finding was determined. It includes findings that were
determined by examination of the patient. Finding method is frequently used with Finding informer.
For example,
713071004 | Alcohol misuser in household (finding) | (http://snomed.info/id/713071004) has the 418775008 |
Finding method (attribute) | (http://snomed.info/id/418775008) of 84100007 | History taking (procedure) | (
http://snomed.info/id/84100007)

Finding site
This attribute specifies the body site affected by a condition.
For example,
90708001 | Kidney disease (disorder) | (http://snomed.info/id/90708001) has 363698007 | Finding site (attribute) | (
http://snomed.info/id/363698007) of 64033007 | Kidney structure (body structure) | (http://snomed.info/id/64033007)

Has interpretation
This attribute refers to and designates the judgment aspect being evaluated or interpreted (e.g. presence, absence,
degree, normality, abnormality, etc.). Interprets and Has Interpretation are grouped together in a relationship group
without any other attributes.
For example,

Figure 3: Inferred view of Inadequate intake of vitamin D and vitamin D derivative (finding)

Interprets
This attribute refers to the entity being evaluated or interpreted, when an evaluation, interpretation, or judgment is
intrinsic to the meaning of a concept.

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Interprets and Has Interpretation are grouped together in a relationship group without any other attributes.
Interprets may be used in a relationship group by itself without any other attributes if the value of the observable is
not defined.
For example,

Figure 4: Stated view of |Decreased muscle tone (finding)|

Modeling
For concepts in the 118245000 | Measurement finding (finding) | (http://snomed.info/id/118245000)
subhierarchy, the value for 363714003 | Interprets (attribute) | (http://snomed.info/id/363714003) should be
an Evaluation procedure or a Laboratory procedure, not an Observable entity.

Has realization
This attribute is used to specify the process or activity that is the consequence of realization of the function.

Modeling Allergy to X
Allergy to X is modeled with 719722006 | Has realization (attribute) | (http://snomed.info/id/719722006) of
472964009 | Allergic process (qualifier value) | (http://snomed.info/id/472964009) and 246075003 | Causative
agent (attribute) | (http://snomed.info/id/246075003) of 105590001 | Substance (substance) | (http://snomed.
info/id/105590001). See template at Allergy to [substance] (finding) for more information including
exceptions.

Occurrence
This attribute refers to the specific period of life during which a condition first presents. However, conditions may
persist beyond the period of life when they first present.
For example,
192611004 | Childhood phobic anxiety disorder (disorder) | (http://snomed.info/id/192611004) has the 246454002
| Occurrence (attribute) | (http://snomed.info/id/246454002) of 255398004 | Childhood (qualifier value) | (
http://snomed.info/id/255398004)

Modeling
Multiple values of 246454002 | Occurrence (attribute) | (http://snomed.info/id/246454002) for a single
concept are not desirable. They will be addressed in a future release.

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Pathological process
This attribute provides information about the underlying pathological process of a disorder, i.e. it describes the
process that results in the structural or morphologic change.
441862004 | Infectious process (qualifier value) | (http://snomed.info/id/441862004) and its subtype 442614005 |
Parasitic process (qualifier value) | (http://snomed.info/id/442614005) are included in the range for 370135005 |
Pathological process (attribute) | (http://snomed.info/id/370135005). These are used in modeling the 40733004 |
Infectious disease (disorder) | (http://snomed.info/id/40733004) subhierarchy.
For example,
17322007 | Disease caused by parasite (disorder) | (http://snomed.info/id/17322007) has the 370135005 |
Pathological process (attribute) | (http://snomed.info/id/370135005) of 442614005 | Parasitic process (qualifier
value) | (http://snomed.info/id/442614005)
370135005 | Pathological process (attribute) | (http://snomed.info/id/370135005)must not be used for values that could
overlap with 116676008 | Associated morphology (attribute) | (http://snomed.info/id/116676008).
For example,
Inflammatory processes result in inflammation (by definition), but these disorders should be defined by their
morphology, i.e. 708039003 | Inflammatory lesion (morphologic abnormality) | (http://snomed.info/id/708039003)
Disorders which involve congenital anomalies are defined with the following grouped attribute-value pairs:
Occurrence (attribute) = congenital (qualifier value)
Associated morphology (attribute) = << 49755003 |Morphologically abnormal structure (morphologic
abnormality)|
Pathological process (attribute) = pathological development process (qualifier value)
Finding site = X (body structure)

Modeling
Congenital X morphology concepts should not be used. They may be used only if there is not a non-
congenital supertype.

Severity
This attribute is used to subclass a Clinical finding concept according to its severity. However, this use is relative, i.e.
it is incorrect to assume that the disease intensity or hazard is the same for all clinical findings to which this attribute
is applied.
Symptom intensity should be considered a separate dimension from disease severity. 246112005 | Severity
(attribute) | (http://snomed.info/id/246112005) is not applied to 162465004 | Symptom severity (finding) | (http://snomed.
info/id/162465004) because:

Severe may be interpreted in different ways, depending on the set of values/value set available. Consider the
different meaning of severity in each of the following sets of values:
mild / moderate / severe
minimal / mild / moderate / severe / very severe
mild / mild to moderate / moderate / moderate to severe / severe / life threatening / fatal
Severity is defined relative to the expected degree of intensity or hazard of the Clinical finding that is being
qualified. For example, the common cold has a baseline intensity or hazard that is much less than a more
serious disease like lupus erythematosus or pneumonia; thus, a severe cold might be considered less intense
or less hazardous than mild pneumonia.
Some disorders that are life-threatening do not ordinarily have a severity assigned to them. Cancer, for
example, is not usually described as mild, moderate or severe, but rather by stage or grade.

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Consequently, 246112005 | Severity (attribute) | (http://snomed.info/id/246112005) cannot be used for all Clinical
findings that may be serious or life-threatening. Nevertheless, it is still useful to subclass certain concepts and to
differentiate between severities of a single disorder.

Modeling
Generally, 246112005 | Severity (attribute) | (http://snomed.info/id/246112005) is not used to model concepts
precoordinated in the International Release, but there are some exceptions. This attribute can be used as
a qualifier in postcoordination.

Temporally related to
This attribute applies to perioperative complications in the clinical finding hierarchy. The attribute has a
subhierarchy that specifies a period of time occurring before, during, or after a procedure; e.g. p erioperative
complications refer to complications temporally related to a surgical procedure. They include preoperative,
intraoperative, and postoperative complications and are modeled with a relationship consisting of 726633004 |
Temporally related to (attribute) | (http://snomed.info/id/726633004) or an appropriate subtype.

Clinical Finding/Disorder Naming Conventions

The fully specified name (FSN) for a concept must be specific. The preferred term (PT) can be a
word-order variant that is more clinician-friendly. For a Clinical finding/Disorder concept,
name the morphologic abnormality before naming the anatomical site.
For example,
399525009 | Inflammation of ampulla of Vater (disorder) | (http://snomed.info/id/399525009), Inflammation is the
morphologic abnormality and ampulla of Vater is the finding site
The FSN must conform to a specific pattern of "Disease of x" where a specific body structure is involved. For the
preferred term, end users can choose the desired description that conforms to common clinical usage.
FSN: Disease of kidney
PT: Can be either 'Kidney disease' or 'Renal disease'
Those conditions which are not described by an anatomical site, such as "Metabolic disease" or "Hereditary disease"
or "Bacterial disease", are exempt from the |Disease of x| naming pattern. "Metabolic disease" is not improved by
specifying "Disease of metabolism", and there is no more specific way to say "Hereditary disease" without making it
convoluted.

Disorder
In the disorder hierarchy, the following naming conventions apply:
The word disorder should be singular, so correct convention is Disorder of nose, not Disorders of nose.

Exceptions
Plurals may be used:
As synonyms for grouper concepts, e.g. disorders or diseases
In bilateral concepts, e.g. Disorder of bilateral eyes, Disorder of both eyes (see also Lateralized
Disorder Naming Conventions)

When the concept is a general grouping of disorders of a body system, body site, or other broad category, the
word disorder is preferred over the word disease for the FSN, e.g. Disorder of reproductive system, not
Disease of reproductive system. This does not apply at the leaf level.
For example,
417683006 | Sickle cell-hemoglobin C disease without crisis (disorder) | (http://snomed.info/id/417683006)

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At risk of X/At risk for X

Use of at risk of X and at risk for X are both acceptable when naming concepts.
Choose which sounds most natural.
Synonyms may include the wording at risk of X and at risk for X, but adding both is not required.
Creating separate concepts, one with at risk of X and one with at risk for X, is not permitted.

Disorder X without Disorder Y

The vast majority of existing X without Y concepts originated from ICD-9 with the specific meaning of "X disorder
without mention of Y disorder". As the phraseology indicates a lack of data about disorder Y as opposed to a specific
exclusion, this type of concept has not been included in ICD-10, nor proposed for ICD-11, except in the case of
"Traumatic brain injury without open intracranial wound".
Addition of new X without Y concepts may only be made under the following conditions:
The request for new content must be accompanied by a rationale as to the difference between "X disorder
without Y disorder" and "X disorder"
Approval of addition by the Head of Terminology
For the most part, e xisting X without Y concepts will be inactivated as AMBIGUOUS with a historical MAY BE
relationship to "X disorder". Exceptions to inactivation will be made on a case-by-case basis.

Region
If the 363698007 | Finding site (attribute) | (http://snomed.info/id/363698007) value of a concept is a body structure with
"region" in its FSN, then the description of the finding site within the clinical finding concept's FSN should also
include "region".
For example, 274205003 | Burn of eye region (disorder) | (http://snomed.info/id/274205003) has a finding site of
371398005 | Eye region structure (body structure) | (http://snomed.info/id/371398005).
FSN: Burn of eye region (disorder)
PT: Burn of eye region

Figure 1: Stated view of |Burn of eye region (disorder)|

Allergy to substances, multiple substances

Previously, allergies caused by multiple substances were modeled by multiple causative agents suggesting that the
allergy is caused by all those substances. However, when multiple substances are noted in the FSN, the intended
clinical meaning is that a patient might be affected by one or more of these substances (or products containing
them). To convey this meaning, these types of concepts should be modeled GCIs to represent the disjunctive
meaning. e.g. 870731003 |Allergy to carbidopa and/or levodopa (finding)|

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Adverse reaction to substances, multiple substances

A description for a ny concept that names a substance should be consistent with the Substance hierarchy
description rules.
For example, 292121007 | Sulfasalazine adverse reaction (disorder) | (http://snomed.info/id/292121007)
FSN: Sulfasalazine adverse reaction (disorder)
PT: Sulfasalazine adverse reaction
For example, 292986000 | Ampicillin + flucloxacillin adverse reaction (disorder) | (http://snomed.info/id/292986000)
FSN: Adverse reaction to ampicillin and/or flucloxacillin (disorder)
PT: Adverse reaction to ampicillin and/or floxacillin (US English)
PT: Adverse reaction to ampicillin and/or flucloxacillin (GB English)

Information
The modeling approach for multiple-ingredient concepts is a temporary solution. It incorrectly asserts an
adverse reaction to each, rather than to one, agent. The use of concepts from the Pharmaceutical
/biologic product hierarchy is being considered as a final solution, but further work is required to
determine if this would be a viable solution.

Adverse reaction caused by organisms

A description for any concept that names an organism should be consistent with the Organism hierarchy
description rules.
Use the scientific name for the organism in the FSN, e.g. Adverse reaction caused by Artemisia vulgaris pollen
(disorder)
Use the common name in the preferred term, e.g. Adverse reaction caused by mugwort
The synonym should match the FSN, e.g. Adverse reaction caused by Artemisia vulgaris pollen

Allergic and nonallergic hypersensitivity (pseudoallergic) dispositions

A description for any concept that names a substance or an organism should be consistent with the corresponding
hierarchy description rules.

Drug allergies
Allergic and nonallergic hypersensitivity (pseudoallergic) concepts include drug allergies.

Allergic and nonallergic hypersensitivity (pseudoallergic) dispositions are the propensity to develop adverse allergic
or nonallergic hypersensitivity (pseudoallergic) disorders.

Disposition Patterns and examples

FSN Patterns:
Allergy to X (finding)
Allergy to X and Y (finding)
X and Y in alphabetical order for concepts representing
multiple substances
For example,
Allergy to abacavir (finding)

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Disposition Patterns and examples

Allergy to Artemisia vulgaris pollen (finding)

PT Patterns:
Allergy to X
Allergy to X and Y
X and Y in alphabetical order for concepts representing
multiple substances
For example,
Allergy to abacavir
Allergy to mugwort pollen

Allergic and nonallergic hypersensitivity (pseudoallergic) disorders

These disorders represent manifestations of pathologic processes that may result in abnormal structures (e.g.,
allergic rhinitis).

Disorder Patterns and examples

FSN Patterns:
FSN: Allergic disease X (disorder)
FSN: Allergic disease X (caused by Y) (disorder)
For example,
Allergic rhinitis (disorder)
Allergic conjunctivitis (disorder)
Allergic rhinitis caused by grass pollen (disorder)
Allergic rhinitis caused by house dust mite (disorder)

PT Patterns:
Allergic disease X
Allergic disease X (caused by Y)
For example,
Allergic rhinitis
Allergic conjunctivitis
Allergic rhinitis caused by grass pollen
Allergic rhinitis caused by house dust mite

Allergic and nonallergic hypersensitivity (pseudoallergic) reactions

These disorders represent pathological processes that are defined as adverse reactions and allergic conditions with
a pathological process of allergic or nonallergic hypersensitivity (pseudoallergic) process.

Reaction Patterns and examples

FSN Patterns:

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Reaction Patterns and examples

Allergic reaction (caused by X) (disorder)

Anaphylactic reaction (caused by X) (disorder)
Anaphylactoid reaction (caused by X) (disorder)
For example,
Allergic reaction caused by dye (disorder)
Allergic reaction caused by pollen (disorder)

PT Patterns:
Allergic reaction caused by X
For example,
Allergic reaction caused by dye
Allergic reaction caused by pollen

Contact hypersensitivity
Contact hypersensitivity represents a response elicited by contact of the skin or mucous membranes with a
substance. The response may be immune mediated (allergic) or nonimmune (irritant) using the pathological
process c ontact hypersensitivity process (qualifier value).
For example,
Contact dermatitis (disorder)
Irritant contact dermatitis (disorder)

Intolerance to substances
An intolerance is the propensity to develop an adverse reaction to a substance. The nature of the adverse reaction
can represent a variety of pathological processes but specifically excludes hypersensitivity (allergic and nonallergic
hypersensitivity (pseudoallergic) reactions.
Due to the difficulty in precisely defining an intolerance pathological process, it is problematic to apply the model
for hypersensitivity dispositions to defining intolerance to substance. For this reason, as well as the difficulty in
associating a material agent with a disposition, substances are related to the intolerance disposition with the
associated with attribute.

Intolerance Patterns and examples

FSN Pattern:
Intolerance to X (finding)
Example,
Intolerance to milk (finding)

PT Pattern:
Intolerance to X
Example,
Intolerance to milk

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Allergy to x vaccine
The terming and modeling editorial guidance for Allergy to X vaccine (for single and multiple ingredient vaccines)
are located at:
Allergy to X vaccine

Adverse reaction to x vaccine

The terming and modeling editorial guidance for Adverse reaction to X vaccine (for single and multiple ingredient
vaccines) are located at:
Adverse reaction to X vaccine

Inadequate and excessive intake of energy and nutrients

Identification of findings of inadequate or excessive intake of nutrients inconsistent with nutrient requirements and
established reference standards includes nutrients with a variety of forms where applicable.
For example, 870465001 | Excessive intake of vitamin A and vitamin A derivative (finding) | (http://snomed.info/id
/870465001)

FSN: Excessive intake of vitamin A and vitamin A derivative (finding)

PT: Excessive intake of vitamin A and vitamin A derivative

Lateralized Disorder Naming Conventions

For more information

See the IHTSDO Authoring Projects; Anatomy Projects webpage Laterality (draft).
See also Naming convention for anatomy (draft) for information on naming concepts referring to
digits.

Right, left disorder concepts

Descriptions
FSN: X (morphologic abnormality) of right/left X (body structure)
PT: Right/left (disorder)
For example, 1089071000119109 | Inflammation of left mastoid (disorder) | (http://snomed.info/id/1089071000119109)
FSN: Inflammation of left mastoid (disorder)
PT: Left mastoiditis

Figure 1: Stated view of |Inflammation of left mastoid (disorder)|

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Bilateral disorder concepts

Descriptions
FSN: X (morphologic abnormality) of bilateral (body structure)
PT: Bilateral X (disorder)
SYN: X (disorder) of bilateral (body structure)
SYN: X (disorder) of both (body structure)
For example, 1084011000119100 | Inflammation of bilateral mastoids (disorder) | (http://snomed.info/id
/1084011000119100)

FSN: Inflammation of bilateral mastoids (disorder)

PT: Bilateral mastoiditis
SYN: Inflammation of bilateral mastoids
SYN: Inflammation of both mastoids

Modeling of bilateral disorders

Bilateral disorders (or procedures) should be modeled using two relationship groups, one for each lateralized body
structure.

Figure 2: Stated view of |Inflammation of bilateral mastoids (disorder)|

Structure, Structure of
Lateralized disorder (and procedure) concepts should not include the words structure or structure of.
For example,
For the body structure concept, 266005 | Structure of lower lobe of right lung (body structure) | (
http://snomed.info/id/266005). a disorder concept with this body structure is 724056005 | Malignant
neoplasm of lower lobe of right lung (disorder) | (http://snomed.info/id/724056005).
For the body structure concept, 266005 | Structure of lower lobe of right lung (body structure) | (
http://snomed.info/id/266005), a procedure with this body structure is 726425007 | Lobectomy of
lower lobe of right lung (procedure) | (http://snomed.info/id/726425007).

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Disorder Modeling
A disorder is always and necessarily an abnormal clinical state.
Disorder modeling information is as follows:

Specific Disorder Modeling

Topic links (by disorder type)

Ischemic disorder (see page )
Ischemic heart disease (see page )
Arrhythmia (see page )
Lesion (see page )
Trauma, injury (see page )
Friction injury, abrasion (see page )
Rupture (see page )
Traumatic disorders (see page )
Tumor vs. neoplasm (see page )
Primary vs secondary neoplastic disorders (see page )
Neoplasia (see page )
Neoplasm vs. hamartoma (see page )
Nevus (see page )
Infectious disease, inflammatory disorder (see page )
Pneumonia vs. Pneumonitis (see page )
Post-infectious Disorders (see page )
Bacterial disorders with organism and/or toxin (see page )
Hypersensitivity (see page )
Iatrogenic (see page )
Congenital (see page )
Congenital vs. acquired (see page )
Hereditary (see page )
Familial (see page )
Developmental (see page )
Genetic, developmental, congenital, and physical (see page )
Malformation, deformation, anomaly (see page )
Hematologic, lymphatic (see page )
Hematologic disorders, lymphoid and myeloid neoplasms (see page )
Coagulation, hemostasis, thrombosis (see page )
Hernias (see page )
Osteoarthritis (see page )
Multisystem disorders (see page )
Mental health disorders (see page )
Death (see page )

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Poisoning (see page )

Vaccine-related overdose (see page )
Obstruction (see page )
Combining Morphologic Abnormalities (see page )
Remission (see page )

Ischemic disorder
Ischemic disorders are defined by a morphology of ischemic structural change. This need not be permanent, but it
is assumed that all ischemia results in some structural alterations at the molecular level.

Ischemic heart disease

Ischemic heart disease includes myocardial infarction, myocardial ischemia (without infarction), angina, and other
disorders of the heart that have ischemic structural change (reversible or non-reversible) as a defining characteristic.
Coronary arteriosclerosis can, of course, be present without causing ischemia, so coronary arteriosclerosis is not a
subtype of ischemic heart disease.
Likewise, there are causes of myocardial ischemia and infarction other than coronary arteriosclerosis, so ischemic
heart disease is not a subtype of coronary arteriosclerosis.

Arrhythmia
Cardiologists noted confusion in the placement of Conduction disorder of the heart (disorder) as a broad grouping
that subsumed arrhythmias and heart blocks. In common usage arrhythmia refers to a broad set of conditions that
include conduction disorders, under which are heart blocks. The concept Cardiac arrhythmia (disorder) is a parent
of Conduction disorder of the heart (disorder), and the active referent of the inactive concepts named dysrhythmia
or arrhythmia.
For example,
Arrhythmias, like 72654001 | Supraventricular arrhythmia (disorder) | (http://snomed.info/id/72654001), are under
698247007 | Cardiac arrhythmia (disorder) | (http://snomed.info/id/698247007)
Conduction disorders include heart block, AV block, bundle branch block, conduction delay, and conduction defect,
like 418341009 | Atrioventricular conduction disorder (disorder) |. Other arrhythmias were moved from under
44808001 | Conduction disorder of the heart (disorder) | (http://snomed.info/id/44808001) and placed under 698247007
| Cardiac arrhythmia (disorder) | (http://snomed.info/id/698247007).

Lesion
The word lesion can be used to refer to both structural and functional abnormalities. If a disorder (or procedure)
refers to a lesion in a way that makes it clear that it is a generic term for a structural abnormality, then the correct
modeling approach is to use 116676008 | Associated morphology (attribute) | (http://snomed.info/id/116676008) =
49755003 | Morphologically abnormal structure (morphologic abnormality) | (http://snomed.info/id/49755003) (For
procedures, use 405816004 | Procedure morphology (attribute) | (http://snomed.info/id/405816004)).
Functional lesions should not be modeled using values from the Morphologically abnormal structure hierarchy.

Trauma, injury
The word trauma has multiple meanings. The first is physical damage to the body (versus emotional trauma). We
assume trauma means physical damage unless accompanied by words that make clear it is emotional.
Injury is not synonymous with trauma since injuries, caused by stroke, drowning, or toxins, for example, are non-
traumatic. Thus the concept, 417163006 | Traumatic AND/OR non-traumatic injury (disorder) | (http://snomed.info/id
/417163006) .

Traumatic injury (disorder)

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417746004 | Traumatic injury (disorder) | (http://snomed.info/id/417746004) is defined as any disorder with a

morphology of 19130008 | Traumatic abnormality (morphologic abnormality) | (http://snomed.info/id
/19130008).

Friction injury, abrasion

An injury due to friction can be represented using 400152004 | Friction injury (morphologic abnormality) | (
http://snomed.info/id/400152004), in which case it will not classify as a kind of wound.

For example,
47222000 | Friction injury of tooth (disorder) | (http://snomed.info/id/47222000)
400068007 | Mechanical irritation (morphologic abnormality) | (http://snomed.info/id/400068007)
However, most disorders that are named abrasion imply that skin or other tissue has been abraded (scraped or worn
away). Thus, they are also considered wounds and will correctly classify as wounds after assigning the correct
morphology, 400061001 | Abrasion (morphologic abnormality) | (http://snomed.info/id/400061001).
For example,
211039006 | Abrasion, chest wall (disorder) | (http://snomed.info/id/211039006)

Rupture
Ruptures can occur either as a result of injury or spontaneously. The word rupture, when applied to muscles and
tendons, implies a traumatic injury (e.g. 239731008 | Rupture of lateral collateral ligament of knee (disorder) | (
http://snomed.info/id/239731008)). Rupture, when applied to an internal organ, may be either traumatic or spontaneous
(e.g. 4240001 | Rupture of aorta (disorder) | (http://snomed.info/id/4240001), 88294009 | Rupture of ovary (disorder) | (
http://snomed.info/id/88294009), etc).

Rupture has the subtype morphologies, 415747007 | Traumatic rupture (morphologic abnormality) | (http://snomed.
info/id/415747007) and 125672000 | Nontraumatic rupture (morphologic abnormality) | (http://snomed.info/id/125672000)
. It is important to make this distinction, at a minimum, in order to support queries related to the effects of trauma.
Modelers choose:
415747007 | Traumatic rupture (morphologic abnormality) | (http://snomed.info/id/415747007) as the value of
associated morphology for concepts involving anatomical sites, such as muscles and tendons, where trauma is
involved (in the absence of a specific lesion).
For example,
209765005 | Rupture of tendon of thumb (disorder) | (http://snomed.info/id/209765005)
125671007 | Rupture (morphologic abnormality) | (http://snomed.info/id/125671007) as th e value of associated
morphology for concepts involving anatomical sites, such as internal organs, where rupture may be traumatic or
spontaneous.
For example,
46126003 | Rupture of artery (disorder) | (http://snomed.info/id/46126003)
125672000 | Nontraumatic rupture (morphologic abnormality) | (http://snomed.info/id/125672000), when it is stated as
such.
For example,
268002004 | Non-traumatic tendon rupture (disorder) | (http://snomed.info/id/268002004)

Traumatic disorders
If an injury/traumatic disorder does not have a morphology which is a sub-class of 19130008 | Traumatic
abnormality (morphologic abnormality) | (http://snomed.info/id/19130008), then an additional relationship group is
added to express this relationship. The relationship is only required for traumatic injury concepts.
These disorders often have an FSN prefixed by injury or explicitly prefixed by traumatic.
Examples of FSNs,

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Injury of brachial plexus trunk (disorder)

Traumatic dislocation of sixth and seventh cervical vertebra (disorder)
Most traumatic concepts have the relationship groups, Finding site and Associated morphology.
For example, 721347007 | Fracture of third cervical vertebra (disorder) | (http://snomed.info/id/721347007) has
Finding site (attribute) = Bone structure of C3 (body structure)
Associated morphology (attribute) = Fracture (morphologic abnormality)
Usually, as in the above example, the morphology is a sub-class of 119130008 | Traumatic abnormality
(morphologic abnormality) | and thus auto-classifies appropriately. However, some morphologies are not currently
sub-classes of Traumatic abnormality, and a traumatic variant does not exist. These morphologies will not auto-
classify as an injury.
For example, 722628000 | Traumatic hemorrhage of subdural space of infratentorial region (disorder) | (http://snomed.
info/id/722628000)

Associated morphology (attribute) = Hemorrhage (morphologic abnormality) and

Finding site (attribute) = Structure of subdural space of infratentorial region (body structure)
In these cases an additional relationship group is added.
For example,
Finding site (attribute) = Structure of subdural space of infratentorial region (body structure) and
Associated morphology (attribute) = Traumatic abnormality (morphologic abnormality)

Tumor vs. neoplasm

The word tumor has two primary meanings, a mass, regardless of whether it is neoplastic or not, or a neoplastic
mass. Neoplasm is preferred since it is less ambiguous than tumor.
For example,
92385005 | Benign neoplasm of small intestine (disorder) | (http://snomed.info/id/92385005)

Primary vs secondary neoplastic disorders

SNOMED CT follows ICD-O and ICD-10, where secondary malignant neoplasm of ( site X) is uniformly interpreted to
mean that metastasis has occurred to site X.
For example,
94521000 | Secondary malignant neoplasm of rib (disorder) | (http://snomed.info/id/94521000)
For concepts that describe metastasis from a malignant neoplasm, SNOMED CT explicitly uses the word from.
For example,
315006004 | Metastasis from malignant tumor of lung (disorder) | (http://snomed.info/id/315006004)
In SNOMED CT, metastases are modeled with two relationship groups, each with an appropriate morphology and
site.
For example,
712849003 | Primary malignant neoplasm of prostate metastatic to bone (disorder) | (http://snomed.info/id
/712849003):

IS A (attribute): Disease (disorder)

Finding site (attribute): Bone structure (body structure) and Associated morphology (attribute):
Neoplasm, metastatic (morphologic abnormality)
Associated morphology (attribute): Malignant neoplasm, primary (morphologic abnormality) and
Finding site (attribute): Prostatic structure (body structure)

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Neoplasia
When modeling neoplasia, distinguish structure from process. Do not use neoplasia in the FSN to identify the
structure (even though it implies it). Use 126537000 | Neoplasm of bone (disorder) | (http://snomed.info/id/126537000),
not neoplasia of bone.

Neoplastic disease refers to the process of neoplasia, leading to the formation of a neoplasm.
Where the definition is primary, the associated morphology: 86049000 | Malignant neoplasm, primary (morphologic
abnormality) | (http://snomed.info/id/86049000) is used.
Where the definition is primary or secondary, the morphology: 367651003 | Malignant neoplasm of primary,
secondary, or uncertain origin (morphologic abnormality) | (http://snomed.info/id/367651003) is used.
Where the concept expresses a specific morphology, the FSN will alway contains the word primary.
For example,
9541000119105 | Primary adenocarcinoma of gallbladder (disorder) | (http://snomed.info/id/9541000119105)
Finding site (attribute): Gallbladder structure (body structure)
Associated morphology (attribute): Adenocarcinoma (morphologic abnormality)

Neoplasm versus hamartoma

A neoplasm is defined as a growth of tissue no longer under normal control. A hamartoma is defined as a benign,
self-limiting growth of disorganized mature cells normally found in the region, representing faulty development.
SNOMED CT has disorder (and morphologic abnormality) concepts and subtypes representing neoplasia,
hamartomas, and tumors.
The SNOMED CT concept 399981008 | Neoplasm and/or hamartoma (disorder) | (http://snomed.info/id/399981008) has
six subtypes:
angiomatosis
hamartoma
hemangioma
lymphangioma
melanocytic nevus
neoplastic disease
The SNOMED CT concept 400177003 | Neoplasm and/or hamartoma (morphologic abnormality) | (http://snomed.info
/id/400177003) also has six subtypes:

angiomatosis
blood vessel tumor
hamartoma
lymphatic vessel tumor
melanocytic nevus
neoplasm

Nevus
The word nevus has many different meanings. The differences are generally based on answers to the following
questions:
Is it necessarily on the skin? Or can it be located in mucosal sites or other sites?
Is it necessarily visible? Or can it be in internal locations such as gastric mucosa, etc?
Is it necessarily present at birth? Or can it occur later in life?
Is it necessarily dark and made of melanocytes? Or can it be non-pigmented, or made of other types of cells?

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Is it necessarily made of tissue that is normally present at the site? Or can it be ectopic?
Does it exclude benign neoplasms?
Some common meanings of nevus based on some combinations of answers to the questions are as follows:
A birthmark, that is, any visible spot on the skin or oral mucosa present since birth, regardless of tissue of
origin, excluding benign neoplasms.
Any benign cluster of melanocytes, regardless of location, and regardless of pigmentation, whether present
since birth or appearing later.
Any cutaneous hamartoma. This excludes non-cutaneous sites, and excludes neoplasms and ectopic tissue,
such as choristomas.
As a result of this wide variation in meaning, any SNOMED CT FSN containing the word nevus may be ambiguous.
For example, the term vascular nevus may mean:
Congenital blood vessel tumor in the skin
Congenital blood vessel hamartoma or neoplasm that is visible somewhere (not only the skin, but also the
mucosa, whether visible externally or not)
Congenital blood or lymphatic vessel tumor in the skin
Congenital blood or lymphatic vessel hamartoma or neoplasm that is visible somewhere
Any of the above but not necessarily congenital
A better FSN for vascular nevus (morphologic abnormality) would be vascular hamartoma (morphologic
abnormality). Likewise, a better FSN for congenital vascular nevus (disorder) would be congenital vascular
hamartoma (disorder).
In those cases where common clinical usage of a term containing nevus is unambiguous, there is no need to
inactivate the description or the concept.

Infectious disease and/or inflammatory disorder

Disorders with the suffix "-itis" (e.g. cystitis, prostatitis, tonsillitis, appendicitis) are often infectious as well as
inflammatory in nature. For inflammatory conditions whose FSNs specify an infective cause , the modeling should
include:
| Causative agent (attribute) | (http://snomed.org/fictid#) with the specified organism
| Pathological process (attribute) | (http://snomed.org/fictid#) with the type of infectious process
| Associated morphology (attribute) | (http://snomed.org/fictid#) with Inflammatory morphology or subtype
| Finding site (attribute) | (http://snomed.org/fictid#) with a body structure when known
An infectious cause should neither be assumed nor modeled when the FSN does not specify it. For inflammatory
conditions whose FSNs do not specify an infective cause, the modeling should exclude a Causative agent and
Pathological process and should include only:
| Associated morphology (attribute) | (http://snomed.org/fictid#) of Inflammatory morphology or subtype
| Finding site (attribute) | (http://snomed.org/fictid#) with a body structure when known
Example of inflammatory and infectious disorder:
441551009 | Inflammation of larynx caused by virus (disorder) | (http://snomed.info/id/441551009)(synonym, Viral
laryngitis) includes a | Causative agent (attribute) | (http://snomed.org/fictid#) of | Virus (organism) | (http://snomed.org
/fictid#) and a | Pathological process (attribute) | (http://snomed.org/fictid#) of | Infectious process (qualifier value) | (
http://snomed.org/fictid#).

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Figure 1: Stated view of 441551009 |Inflammation of larynx caused by virus (disorder)|

Example of inflammatory disorder not specified as infectious:
446292002 | Necrotizing inflammation of lymph node (disorder) | (http://snomed.info/id/446292002) (synonym,
Necrotizing lymphadenitis) does not specify an infective cause, so it is neither modeled with Causative agent nor
Pathological process. The model contains an | Associated morphology (attribute) | (http://snomed.org/fictid#) and a |
Finding site (attribute) | (http://snomed.org/fictid#).

Figure 1: Stated view of 446292002 |Necrotizing inflammation of lymph node (disorder)|

Pneumonia vs. Pneumonitis

The terms pneumonia and pneumonitis are often used interchangeably. In SNOMED CT, pneumonia should be used
for infectious causes, and pneumonitis should be used for noninfectious causes.
Pneumonia is a type of pneumonitis, as inflammation is present in both. The distinguishing feature between the two
disorders is the presence of infection in pneumonia. Pneumonia should have a pathological process of infectious
process, pneumonitis should not.
Consolidation is a feature of most forms of pneumonia. It may not be a feature of some atypical pneumonias, e.g.
mycoplasma pneumonia.
Except as noted above, the morphologic abnormality for 233604007 | Pneumonia (disorder) | (http://snomed.info/id
/233604007) is 707496003 | Inflammation and consolidation (morphologic abnormality) | (http://snomed.info/id
/707496003).

The morphologic abnormality for 205237003 | Pneumonitis (disorder) | (http://snomed.info/id/205237003) is 409774005

| Inflammatory morphology (morphologic abnormality) | (http://snomed.info/id/409774005).

Post-infectious disorders
Post-infectious disorders are not subtypes of infectious disorders. The After attribute is used for linking post-
infectious disorders with their associated infections.

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Bacterial disorders with organism and/or toxin

In modeling some bacterial disorders, there will be situations where either the organism or the toxin (substance), or
both values, are required for the causative agent attribute. The decision is often determined by whether or not the
bacteria are considered endotoxins or exotoxins. The most common exotoxins are:
Botulinum Toxin
Enterotoxin
Cholera Toxin
Diphtheria Toxin
Tetanospasmin
Exotoxins are more lethal in comparison to endotoxins, but there are vaccines against many exotoxins whereas
there are no vaccines against endotoxins. There can be instances where an infection is present but the disease-
causing toxins are not; in this case, model the concept only with the organism and not the toxin substance.
Example,
276202003 | Infection caused by Clostridium tetani (disorder) | (http://snomed.info/id/276202003) is modeled with a
causative agent of 30917009 | Clostridium tetani (organism) | (http://snomed.info/id/30917009) only.
In the situation where a disease is caused by both the infection and the associated toxin, model with both the
causative agent and the toxin substance.
Example,
76902006 | Tetanus (disorder) | (http://snomed.info/id/76902006) is modeled with a causative agent of 30917009 |
Clostridium tetani (organism) | (http://snomed.info/id/30917009) as well as 26159005 | Clostridium tetani toxin
(substance) | (http://snomed.info/id/26159005).

Hypersensitivity
473010000 | Hypersensitivity condition (finding) | (http://snomed.info/id/473010000) is a primitive concept. It subsumes
473011001 | Allergic condition (finding) | (http://snomed.info/id/473011001) and 609405001 | Non-allergic
hypersensitivity condition (finding) | (http://snomed.info/id/609405001).
473010000 | Hypersensitivity condition (finding) | (http://snomed.info/id/473010000) is a direct descendant of
404684003 | Clinical finding (finding) | (http://snomed.info/id/404684003).
473011001 | Allergic condition (finding) | (http://snomed.info/id/473011001) and 609405001 | Non-allergic
hypersensitivity condition (finding) | (http://snomed.info/id/609405001) are both primitive concepts. Each has three
main subhierarchies representing:
Diseases/disorders: abnormal structures
Processes: allergic and nonallergic hypersensitivity (pseudoallergic) reactions
Dispositions: propensities to develop allergic and nonallergic hypersensitivity (pseudoallergic) reactions; they
do not have pathophysiologic manifestations prior to allergic and nonallergic hypersensitivity
(pseudoallergic) processes, i.e. reactions
Diseases/disorders and reactions, but not dispositions, are defined by underlying pathological processes.

Pathological process (qualifier value) hierarchy

In order to fully describe the full range of hypersensitivity responses, there are qualifier values in the
Pathological process (qualifier value) hierarchy. (See also Qualifier Value page).

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Disorders of immune function

Allergic reaction
419076005 | Allergic reaction (disorder) | (http://snomed.info/id/419076005) has a causative agent (attribute) of
105590001 | Substance (substance) | (http://snomed.info/id/105590001).

Figure 3: Stated view of 15920201000119103 |Allergic reaction caused by fish (disorder)|

Modeling 414029004 | Disorder of immune function (disorder) | (http://snomed.info/id/414029004) with 769247005 |
Abnormal immune process (qualifier value) | (http://snomed.info/id/769247005) allows allergic and autoimmune
disorders to correctly classify as disorders of immune function.

Allergic and nonallergic hypersensitivity (pseudoallergic) disease

Allergic and nonallergic hypersensitivity (pseudoallergic) diseases represent manifestations of pathologic processes
that result in abnormal structures. Modeling an allergic and nonallergic hypersensitivity (pseudoallergic) disease
includes the following relationship groups:
116676008 | Associated morphology (attribute) | (http://snomed.info/id/116676008) and 363698007 | Finding site
(attribute) | (http://snomed.info/id/363698007) representing the abnormal structure
Pathological process: 472963003 | Hypersensitivity process (qualifier value) | (http://snomed.info/id/472963003), or one
of its descendants
246075003 | Causative agent (attribute) | (http://snomed.info/id/246075003): substance (if specified)

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Figure 4: Allergic and nonallergic hypersensitivity (pseudoallergic) disease model

For example,

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Allergic and nonallergic hypersensitivity (pseudoallergic) disposition

Allergic and nonallergic hypersensitivity (pseudoallergic) dispositions are propensities to develop allergic and
nonallergic hypersensitivity (pseudoallergic) reactions; they do not have pathophysiologic manifestations prior to
reactions. They are considered clinical findings, not disorders. This further distinguishes them from allergic and
nonallergic hypersensitivity (pseudoallergic) reactions.

Figure 5: Allergic and nonallergic hypersensitivity (pseudoallergic) disposition model

For example,

Figure 6: Allergic disposition (finding) modeling

Allergic and nonallergic hypersensitivity (pseudoallergic) reaction

Allergic and nonallergic hypersensitivity (pseudoallergic) reactions are adverse reactions and allergic conditions. Like
diseases/disorders, they are defined by underlying pathological processes.

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Figure 7: Allergic and nonallergic hypersensitivity (pseudoallergic) reaction model

For example,

Intolerance to substance
An intolerance is the propensity to develop an adverse reaction to a substance. The adverse reaction may be
associated with various pathological processes, but specifically excludes hypersensitivity reactions.
It may be difficult to define the pathological process and to associate the substance with the propensity to develop
a reaction. Consequently, 47429007 | Associated with (attribute) | (http://snomed.info/id/47429007) is used to model
intolerance to substances.

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Figure 8: Stated view of |Intolerance to substance (finding)| model

For example,

Iatrogenic
Adding to the iatrogenic disorder hierarchy is discouraged. An iatrogenic disorder should remain as a primitive
concept. It should be a child of 116223007 | Complication (disorder) | (http://snomed.info/id/116223007). Iatrogenic is
not available as a value of 263547006 | Pathogenesis (attribute) | (http://snomed.info/id/263547006).
Subytypes of 12456005 | Iatrogenic disorder (disorder) | (http://snomed.info/id/12456005) that have FSNs without the
word iatrogenic, should be remodeled by inactivating the IS_A relationship to 12456005 | Iatrogenic disorder
(disorder) | (http://snomed.info/id/12456005).
Concepts with iatrogenic in the FSN should be modeled with an IS_A relationship to 12456005 | Iatrogenic disorder
(disorder) | (http://snomed.info/id/12456005).
For example,

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Figure 9: Inferred view of 232081005 |Iatrogenic glaucoma (disorder)| using IS_A 12456005 |Iatrogenic disorder
(disorder)|

Congenital
The concept 66091009 | Congenital disease (disorder) | (http://snomed.info/id/66091009), means present at birth.
Though the word congenital may be applied to genetic disorders, the term genetic is preferred for those disorders.
The logical definition of a congenital disorder must include:
Occurrence = Congenital (qualifier value).
It may also include:
Finding site = X (body structure)
Associated morphology = X (morphologic abnormality)
Pathological process = Pathological development process (qualifier value)
The relationship, | Pathological process (attribute) | (http://snomed.org/fictid#) = | Pathological developmental process
(qualifier value) | (http://snomed.org/fictid#), is required when the concept definition includes an | Associated
morphology (attribute) | (http://snomed.org/fictid#).
All of these defining relationships should be grouped to indicate that the abnormal morphology occurs at the
finding site, results from a pathological development process, and is present at birth. Where a morphologic
abnormality occurs at more than one finding site, or one body structure has multiple morphologic abnormalities,
multiple relationship groups should be created and the pathological process and occurrence relationships included
in each relationship group.
The following guidelines apply:
A disorder with the word congenital in the FSN should classify under 66091009 | Congenital disease (disorder) | (
http://snomed.info/id/66091009).

Congenital X (morphologic abnormality) concepts are being inactivated hence Congenital anomaly disorder
grouper concepts, such as 9904008 | Congenital anomaly of cardiovascular system (disorder) | (http://snomed.info/id
/9904008) , should be modeled with an Associated morphology (attribute) of 49755003 |Morphologically abnormal
structure (morphologic abnormality)I and a Pathological process relationship.
Whether creating new or revising existing concepts, only use Congenital X (morphologic abnormality) concepts if
no non-congenital supertype of that morphologic abnormality is active.
For example, use 399898009 | Misalignment (morphologic abnormality) | (http://snomed.info/id/399898009)not
102283003 | Congenital misalignment (morphologic abnormality) | (http://snomed.info/id/102283003).

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Acquired abnormality of congenital anomaly

For those concepts that describe a congenital anomaly that has been repaired and subsequently acquired an
abnormality, follow the naming convention of |Acquired abnormality of X following repair of congenital X (disorder)
|.
For example,
871598001 | Acquired abnormality of common arterial trunk following repair of truncus arteriosus (disorder) | (
http://snomed.info/id/871598001)

Congenital versus acquired

Disorders may be either congenital or acquired. The acquired form should only exist when there is a need to
differentiate from the congenital form not but not when no congenital variant exists.
Congenital disorders are modeled using 246454002 | Occurrence (attribute) | (http://snomed.info/id/246454002) of
255399007 | Congenital (qualifier value) | (http://snomed.info/id/255399007). If the FSN does not include congenital, it
should not be modeled as congenital. The precise meaning of the FSN should be followed (e.g. many hereditary
disorders have congenital appearances).
For example, 33534005 | Congenital bowing of femur (disorder) | (http://snomed.info/id/33534005) is modeled with
246454002 | Occurrence (attribute) | (http://snomed.info/id/246454002) of 255399007 | Congenital (qualifier value) | (
http://snomed.info/id/255399007)

Figure 10: Stated view of 33534005 |Congenital bowing of femur (disorder)|

Acquired disorders are those that originate and manifest after birth. The disorders are associated with a period of
life, as opposed to a specific process or structure. All diseases (disorders) that occur after birth are considered
acquired.
Generally, concepts that explicitly state acquired in the FSN or in a synonym should be modeled with Occurrence =
767023003 | Period of life beginning after birth and ending before death (qualifier value) |.
For example, see 240253004 |Acquired abduction deformity of foot (disorder)|

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Neonatal period
According to the American Medical Association, the periods of life in the postnatal period include all
periods after birth including the neonatal or immediate postpartum period. It may be challenging to
differentiate a congenital disorder from a neonatal disorder. A condition may be present at birth, i.e.
congenital; however, clinical manifestations may take longer to appear, i.e. during the neonatal period (e.
g. 14333004 | Alloimmune neonatal neutropenia (disorder) | (http://snomed.info/id/14333004)).

Modeling: Acquired disorders

When revising acquired disorders, remove any acquired morphologies and replace with general parent
morphologies, e.g. replace 127560004 | Acquired deformity (morphologic abnormality) | (http://snomed.info
/id/127560004) with 6081001 | Deformity (morphologic abnormality) | (http://snomed.info/id/6081001). Then
add Occurrence attribute with a value of 767023003 | Period of life beginning after birth and ending
before death (qualifier value)|. One of its children may also be used if the FSN states the period of life,
such as Childhood or Adulthood.

Hereditary
It may be a challenge to classify a condition as a 32895009 | Hereditary disease (disorder) | (http://snomed.info/id
/32895009). Hereditary requires case-by-case definition; it cannot be applied to broad categories. Nevertheless, the
names by which many diseases are known include the term, and it is permitted, as long as it does not introduce
ambiguity.

Familial
The term familial may also be ambiguous when used for broad categories. It may mean that the disorder is found in
higher proportions in the immediate or extended family compared to other groups. Or, it may mean there is a
possibility of a disease being inherited. It may be used; however, it may require clarification of meaning from the
requestor. It should not be used as a synonym for genetic.

Developmental
Developmental is a useful label for disorders that affect developing structures or functions that may occur during
pre- or postnatally. They may be present at birth or develop later.

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Genetic, developmental, congenital, and physical

The following figure shows the structure of genetic, developmental, and congenital categories, along with non-
genetic, non-developmental, and postnatal categories. A dimension, called extrinsic physical force, is included to
distinguish deformations from malformations. The sections of the diagram represent categories formed from the
combination of the dimensions, each which represents the answer to one of the following questions:
Is it genetic or not?
Is it developmental or not?
Is it present at birth or not?
Is it due to an extrinsic physical force or not?

Figure 11: The relationships of genetic, congenital, developmental, and acquired disordersExplanation of Figure
The sections with diagonal hashed lines represent combination categories that do not occur.
For example, there are no genetic disorders that are due to an extrinsic physical force. Likewise, there are no
congenital disorders that are considered non-developmental.
The sections with blue crossing lines represent congenital malformations; they may be either genetic or non-
genetic.
For example, congenital infectious malformations
The red circle represents congenital genetic malformations.
The blue sections represent acquired, i.e. disorders that are non-genetic and not present at birth.
For example, Vitamin D deficiency (rickets) in children is a non-genetic, non-congenital, developmental
malformation.
The white sections represent genetic congenital or genetic postnatal disorders.

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For example, Huntington's disease is a genetic disease that is neither congenital nor developmental. The gene
defect is present at birth, but the disease does not manifest until adulthood.
Arrows leading from the sections point to examples of disorders for the category.

Malformation, deformation, anomaly

A deformation is a structural abnormality that is due to an extrinsic physical force. Newly created concepts
representing a deformity should be considered disorders.
Malformations are structural abnormalities that result from intrinsically disordered development. The word anomaly
is, by itself, ambiguous. It may mean: any abnormality including non-structural ones; malformation; both
malformation and deformation. Concepts with the word anomaly must be evaluated for ambiguity.
For example,
Congenital anomaly of <x structure> is definitely structural, but is not the same as congenital malformation
(structural abnormality due to intrinsically disordered development present at birth). Therefore, it can be
regarded as having the more general meaning of structural abnormality present at birth.

Hematologic, lymphatic
There is more than one meaning of hematologic. A definition based on hematological system structure includes
hematopoietic and lymphoid structures (including bone marrow, spleen, thymus, lymph nodes, etc), as well as the
cellular components of blood. Hematologic neoplasms clearly fit this definition.
A definition based on clinical usage by hematologists is broader. Disorders of hemostasis and thrombosis are often
managed by hematologists, but these do not have a common structural overlap with the lymphoid and
hematopoietic systems (with the exception of platelets and megakaryocytes). For clarity, hematologic disorder is a
navigational concept that is used to define a reference set that includes disorders of blood and blood forming
organs, as well as disorders of hemostasis and thrombosis, depending on what is intended.

Hematologic disorders, lymphoid and myeloid neoplasms

Hematologic disorders may refer to disorders of: hematopoietic cell origin; blood forming organs (bone marrow,
lymph nodes, spleen, thymus, and other lymph tissues); cellular components of blood; or function of hemostatic
and thrombotic systems.
Diseases of the blood forming organs (bone marrow, lymph nodes, etc.) can be defined by any one or a
combination of the following:
The morphology (neoplastic diseases, at a minimum, include those morphologies covered by neoplasms in the
International Classification of Diseases for Oncology, ICD-O).
For example,
118599009 | Hodgkin's disease (disorder) | (http://snomed.info/id/118599009) has 128930002 | Hodgkin
lymphoma - category (morphologic abnormality) | (http://snomed.info/id/128930002). The body site involved
(especially specific lymph node groups or skin sites).
For example,
400122007 | Primary cutaneous T-cell lymphoma (disorder) | (http://snomed.info/id/400122007) has Finding site,
skin structure (body structure)
For some disorders, like T-cell lymphomas, and plasma cell and immunosecretory disorders, it is important to
distinguish those defined by morphology, site, or manifestation.
T-cell lymphomas can be subcategorized according to the primary site, a lymph node, the skin, or other extranodal
site. This means that a site of lymphoid structure cannot be the defining characteristic of the parent concept T-cell
lymphoma. Its defining attribute should be morphology alone.
Plasma cell and immunosecretory disorders (e.g. monoclonal gammopathy, heavy chain disease, Waldenstrom's
macroglobulinemia) are defined by their manifestations, i.e. the type of monoclonal protein they secrete. Others (e.
g. myeloma, plasmacytoma) are defined by their morphology, regardless of whether or not they are secretory.
Immunosecretory disorders may have a morphology of plasma cell neoplasm, even though no mass has been
identified and the monoclonal protein may be the only evidence that there is a clonal neoplasm.

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In general, lymphoid and myeloid neoplasms can be modeled with their morphologies, but without a site.
Leukemias and myelodysplastic syndromes are modeled with Finding Site, bone marrow structure (body structure).

Coagulation, hemostasis, thrombosis

There is more than one meaning of coagulation. A broad meaning, to stop bleeding, is better described as
hemostasis. A more narrow definition, limited to the formation of the fibrin clot, might exclude certain components
of hemostasis (e.g the ability to stop hemorrhage through the actions of blood vessels, collagen, endothelial cells,
and platelets, in the absence of clotting). Individuals with congenital fibrinogen deficiency cannot form fibrin clots,
yet their bodies are able to stop bleeding. Therefore, coagulation disorders are kinds of hemostatic disorders.

Hernias
Hernias involve two body structures, one is the hernial opening and the other is the herniated structure. When
modeling hernias, use two role groups to represent the body structures and the associated morphology for each
site. If the herniated structure is not explicit, use the supertype concept for the finding site.
For example, the concept 50063009 | Femoral hernia (disorder) | (http://snomed.info/id/50063009) is modeled with
finding site = 19203006 | Structure of abdominopelvic viscus (body structure) | (http://snomed.info/id/19203006) to
represent the herniated structure.

Osteoarthritis
396275006 | Osteoarthritis (disorder) | (http://snomed.info/id/396275006) is regarded as a degenerative disease, despite
the -itis in its name. Because of this, 396275006 | Osteoarthritis (disorder) | (http://snomed.info/id/396275006) is not a
subtype of arthritis in the disorder hierarchy but instead, the more general, 399269003 | Arthropathy (disorder) | (
http://snomed.info/id/399269003). Arthritis is inflammatory by definition, but osteoarthritis has a subclass in the medical
literature called non-inflammatory osteoarthritis. In fact, according to many authoritative sources, osteoarthritis is
usually regarded as a non-inflammatory disease, and therefore it is not strictly a subtype of arthritis.
Structuring the hierarchy this way does not imply that there are no cases of osteoarthritis with inflammation, nor
does it rule out inflammation as an etiologic or contributory factor. It is well established that inflammation often
occurs in osteoarthritis, and treatment with anti-inflammatory agents has been more effective than pure analgesics
in many cases. Despite growing evidence of the role of inflammatory cytokines in osteoarthritis, it is not always
necessarily an inflammatory disorder of the joint.

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Multisystem disorders
Multisystem disorders are often rare conditions. There may be limited information about such disorders, so they
should be carefully modeled.
When determining parent concepts:
A multisystem parent concept should be included.
Genetic or inherited disorders should be modeled in the same way as other genetic and inherited disorders.
The manifestations of the disorder must always necessarily be true before assigning the relevant parents.
Attributes must also always necessarily be true.
For example,
In 702410002 | Iris coloboma with ptosis, hypertelorism, and mental retardation (disorder) | (http://snomed.info
/id/702410002), the coloboma of the iris is not always present. This would not be explicitly modeled in the
relationships.
Some multisystem disorders can be named by their manifestations. The FSN should be descriptive rather than just a
list of names.
For example,
717909004 | Bilateral microtia with deafness and cleft palate syndrome (disorder) | (http://snomed.info/id
/717909004)

A multisystem disorder with an eponymous syndrome name should be included as a synonym only.

Mental health disorders

Dependence-related concepts which express the current existence of abuse are acceptable.
For example,
191816009 | Drug dependence (disorder) | (http://snomed.info/id/191816009)
Dependence-related concepts which express the pattern as either continuous or episodic are not acceptable.
Unacceptable patterns,
X with single episode
X with multiple episodes
Current episode of X
First episode of X
X with continuous pattern
Unacceptable legacy concepts,
Drug abuse, continuous (disorder)
Episodic drug abuse (disorder)
Concepts describing full or partial remission are acceptable but not the phase of the remission. The patterns are:
X in full remission
X in partial remission
For example,
46244001 | Recurrent major depression in full remission (disorder) | (http://snomed.info/id/46244001)
5703000 | Bipolar disorder in partial remission (disorder) | (http://snomed.info/id/5703000)
Unacceptable examples,
X in early full remission
X in sustained full remission

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X in sustained partial remission

Conditions with associated symptoms should be expressed and modeled like combined disorders. Co-occurrent and
Due to, and Due to situations are acceptable, but not simple Co-occurrent.
For example,
724665004 | Perceptual disturbances co-occurrent and due to sedative withdrawal (disorder) | (http://snomed.
info/id/724665004)

Concepts containing X without Y are considered on a case-by-case basis.

For example,
724735003 | Oppositional defiant disorder without chronic irritability-anger (disorder) | (http://snomed.info/id
/724735003)

Unacceptable example,
Bipolar type II disorder with current episode moderately depressive without psychotic symptoms

Death
Death is an event, not a disorder.

Sudden cardiac death

Sudden cardiac death is a term used in clinical practice. It refers to an arrhythmia that results in sudden loss of
cardiac function which, if not quickly reversed, will lead to actual death. The FSN Sudden cardiac death (disorder) is
modeled as a subtype of 127337006 | Acute heart disease (disorder) | (http://snomed.info/id/127337006). It should not
be classified as death. Individuals with sudden cardiac death have not necessarily been declared dead and are
frequently revived. It is regarded as a subtype of cardiac dysrhythmia.

Poisoning
When modeling poisoning disorders, ensure that the disorder being described is caused by the substance or active
ingredient in the product selected as the causative agent (attribute) value. Do not add poisoning disorders if the
causative agent is a product constituent (e.g. adjuvant, carrier, preservative, flavoring, stabilizer, or other inactive
ingredient) that cannot be identified as the causative agent.

Vaccine-related overdose
For the January 2020 Release, vaccine-related overdose concepts in the Clinical Finding/Disorder hierarchy were
inactivated. They were replaced with concepts in the Event hierarchy, see 788094008 | Excessive dose of vaccine
administered (event) | (http://snomed.info/id/788094008) and subtypes.
When authoring, determine whether the concept describes an overdose, which is a disorder, or the administration
or ingestion of an excessive dose, which is an event.

Vaccine-related poisoning
Vaccine-related poisoning concepts have been inactivated.

Obstruction
Since an obstruction describes blockage inside the space of a tubular structure, the Finding site of obstruction
concepts should be a value from the 113342003 |Structure of lumen of body system (body structure)| subhierarchy.
For example, w hen modeling gastrointestinal tract obstruction concepts, the Finding site value should be a value
from the 432899004 |Structure of lumen of gastrointestinal tract (body structure)| hierarchy as the site obstructed is
the lumen of the tract. A t present, some but not all anatomy content exists to support this model for tracts, ducts
and blood vessels beyond the gastrointestinal tract but is expected in the future.

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Combining Morphologic Abnormalities to Prevent Multiple Groups

When modeling a concept requiring two role groups with the same body structure but two different morphologies
(because a combined morphology does not exist), then those morphologic abnormalities can be combined to
create a single |(morphologic abnormality)| concept. Keep the newly-created morphologic abnormality concept
primitive as all morphologic abnormality concepts are primitive.

Example: Modeling

Concept Associated morphology Associated morphology Associated (combined)

morphology

400067002 | 25201003 | Epidermal 43327007 | Acantholysis 787085004 | Acantholytic

Acantholytic epidermal nevus (morphologic (morphologic epidermal nevus
nevus (disorder) | ( abnormality) | ( abnormality) | ( (morphologic abnormality) | (
http://snomed.info/id http://snomed.info/id http://snomed.info/id http://snomed.info/id/787085004)
/400067002) /25201003) /43327007)

Another example is 1076491000119102 | Nontraumatic complete rupture of muscle or tendon structure of rotator
cuff of left shoulder (disorder) | (http://snomed.info/id/1076491000119102).
If this disorder had the same finding site of |Structure of rotator cuff of left shoulder (body structure)| with two
different morphologic abnormalities of |Nontraumatic rupture| and |Complete rupture|, then those two
morphologic abnormality concepts can be combined to create a single, primitive, morphologic abnormality
concept of |Nontraumatic complete rupture (morphologic abnormality)|. This will prevent modeling with two
relationship groups.
Instead of this:

Model like this:

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Disorder in remission
<X> disorder in remission concepts require a stated relationship to the appropriate primitive Disorder in remission
supertype, in addition to the appropriate supertype for the disorder. With the latter, where the primitive supertype
for the disorder is |Disease (disorder)|, only the Disorder in remission supertype will be required.
For example,
16270831000119107 | Bulimia nervosa in partial remission (disorder) | (http://snomed.info/id/16270831000119107) has
stated parents of 78004001 | Bulimia nervosa (disorder) | (http://snomed.info/id/78004001) and 765207007 | Disorder in
partial remission (disorder) | (http://snomed.info/id/765207007).

91856007 | Acute lymphoid leukemia in remission (disorder) | (http://snomed.info/id/91856007) has only one stated
parent of 765205004 | Disorder in remission (disorder) | (http://snomed.info/id/765205004) because a potential
supertype of 64572001 | Disease (disorder) | (http://snomed.info/id/64572001) would be unnecessary.

Disorder Combination Modeling

There are many disorders that can occur in combination in the same patient. Guidance on the modeling and
terming of FSNs for disorder combinations simplifies available options to achieve consistency. C linically significant
disorder combinations are represented in Snomed by a single concept so that implementers can document
temporal, causal, and/or other relationships between the conditions.
As a means of expressing an association between conditions, one of the following associations is used:
Simple co-occurrence: where two or more conditions have no known causal or temporal relationship but are
found together more often than by random chance
Causation 1: where the cause is another finding or disorder, an event, or procedure
Causation 2: where the cause is a physical force, physical object, organism, or substance

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Causality
Whether Y follows X incidentally or Y is caused by X, is fundamentally different. Causal relationships between
disorders are represented using the 42752001 | Due to (attribute) | (http://snomed.info/id/42752001)when X is not
merely a risk factor for Y, and it is reasonable to believe that the association between X and Y is not just
coincidental.
When modeling a disorder due to another disorder, do not use 116223007 | Complication (disorder) | (http://snomed.
info/id/116223007) as a supertype.

When modeling a disorder due to a procedure, use 116223007 | Complication (disorder) | (http://snomed.info/id
/116223007) as a supertype.

Truth Table
When considering disorder combinations two questions can be asked:

1. Is there a causal relationship?

2. What is the temporal relationship?

The following truth table provides the possible combinations/answers. It allows authors to assign combination
disorders to one category, to which the appropriate modeling and FSN construction is applied. The stricter rules for
FSN construction do not prevent the addition of more familiar connectives in other descriptions, for example with,
or associated with.

Is there a stated causal relationship?

Yes, cause is Yes, cause is a physical No

another finding, object or force, organism,
disorder, or event or substance

What is the Not X due to Y X caused by Y X and Y should be documented

temporal stated separately
relationship?
X follows X due to Y NA X after Y
Y
X after Y

X X due to Y NA X before Y
precedes
X before Y
Y

X occurs X due to Y NA X during Y

during Y
X during Y

X occurs X due to Y NA X temporally related to Y

before,
X temporally related
during,
to Y
and/or
after Y

Temporally related to and subtypes, before and during are only approved to model perioperative
complications
All after relationships are considered to be sequelae
Sequelae which are also complications (late complications) are modeled using both due to and after
relationships

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Modeling
Document multiple conditions in a single statement only for syndromes or strong associations based
on a common predisposing factor.

Simple co-occurrence

Simple co-occurrence

Default modeling pattern Default FSN

Assign each participating disorder as a supertype (or ensure that each FSN: X with Y
participating disorder is present in the ancestor tree following
PT: Eponyms may be used if
classification)
available and acceptable
Use simple co-occurrence for two or more conditions that are strongly
associated by means other than causality or a temporal relationship (e.g. a
common predisposition) where representing such conditions as separate
statements would result in a loss of the associated between the conditions,
such as:
Named syndromes, such as 398114001 | Ehlers-Danlos syndrome
(disorder) | (http://snomed.info/id/398114001)
Manifestations of systemic disorders, such as 83901003 | Sjögren's
syndrome (disorder) | (http://snomed.info/id/83901003)
Do not use simple co-occurrence for those disorders with more than one
anatomical site or more than one associated morphology. Those disorders
should rather be represented as individual concepts in a medical record.

Examples:

41931000119102 | Sinusitis co-occurrent with nasal polyps (disorder) | (http://snomed.info/id/41931000119102)

714203003 | Acute bronchitis co-occurrent with bronchiectasis (disorder) | (http://snomed.info/id/714203003)

Incorrectly named legacy examples (not to be repeated):

Psoriasis-eczema overlap condition (disorder)

Hay fever with asthma (disorder)

Modeling
There are complications which likely exist prior to a disorder or procedure.
For example, the legacy term, 609454008 | Induced termination of pregnancy complicated by acute
necrosis of liver (disorder) | (http://snomed.info/id/609454008)
Acute necrosis of liver is the complication however, temporally it is neither due to nor during. It
was likely to be present prior to the procedure.
The concept will be inactivated. The concepts, 714812005 | Induced termination of pregnancy
(procedure) | (http://snomed.info/id/714812005) and 197269008 | Acute necrosis of liver (disorder) | (
http://snomed.info/id/197269008), should be used for documentation in the medical record.

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Pattern Variance
The requestor submission FSN may be used as preferred term even if it does not comply with the
above recommended pattern.
Exceptions may exist to the above policy which will need to be reviewed on a case-by-case basis.

Causation 1

Cause is another finding, disorder, event or procedure

Default modeling pattern Default FSN construction

Assign the resultant caused disorder as a supertype (or Where X occurs due to another disorder, procedure,
ensure that the caused disorder is present in the ancestor or event Y (which is no longer necessarily present),
tree following classification). construct an FSN of the form: X due to Y
Assign the causal disorder as the target of a due to
relationship.
Add concept 116223007 | Complication (disorder) | (
http://snomed.info/id/116223007) as a supertype only if
caused disorder is the result of a procedure

Examples:

735200002 | Absence of lower limb due to diabetes mellitus (disorder) | (http://snomed.info/id/735200002)

735621005 | Adhesions due to endometriosis (disorder) | (http://snomed.info/id/735621005)

Incorrectly named legacy examples (not to be repeated):

Neutropenia associated with acquired immunodeficiency syndrome (disorder)

Dilated cardiomyopathy secondary to granuloma (disorder)

There are approximately 600 legacy concepts modeled as co-occurrent and due to. They should remain pending
further analysis. Do not add new concepts as co-occurrent and due to, instead model with the due to attribute.

Umbilical cord complication

Model as IS A 362972006 | Disorder of labor / delivery (disorder) | (http://snomed.info/id/362972006)
due to X (disorder).
The concept, 48287005 | Umbilical cord complication (disorder) | (http://snomed.info/id/48287005), is
to be inactivated.

Causation 2

Cause is a material entity; means of exposure/introduction are not significant (if significant, then the causal factor
is an event and treated as Causation 1)

Default modeling pattern Default FSN and PT

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Causation 2

Assign the caused disorder as a Where X occurs due to exposure to material entity Y, construct an FSN
supertype or ensure that the caused of the form: X caused by Y
disorder is present in the ancestor tree
following classification
Assign the causal factor as the target
of a Causative agent relationship

Examples:

291000119100 | Contact dermatitis caused by chemical (disorder) | (http://snomed.info/id/291000119100)

17322007 | Disease caused by parasite (disorder) | (http://snomed.info/id/17322007)

Incorrectly named legacy examples (not to be repeated):

Choking due to airways obstruction (finding)

Coma associated with diabetes mellitus (disorder)

Temporal sequencing, without necessary implication of causation

Modeling captures and emphasizes non-overlap. Explicit causation may be captured using both due to AND after
relationships, as in the truth table above.

Default modeling pattern Default FSN construction

Assign the second/following disorder as a supertype, Where X occurs after Y (and it is not specified that X is
or ensure that the caused disorder is present in the due to Y although causality is frequently implied),
ancestor tree following classification construct the FSN as: X following Y
Assign the first/followed disorder or procedure as the Where X occurs after Y (and it is specified that X is due
target of an after relationship to Y), construct the FSN as: X due to and following Y
For two or more disorders, assign a super type of
362977000 | Sequela (disorder) | (http://snomed.info/id
/362977000) if a causal relationship is also stated

For disorders due to a procedure, assign an additional

supertype of 116223007 | Complication (disorder) | (
http://snomed.info/id/116223007) if a causal relationship is
also stated

Examples:

402490007 | Calcinosis following localized fat necrosis (disorder) | (http://snomed.info/id/402490007)

391103005 | Adverse event following complementary therapy (disorder) | (http://snomed.info/id/391103005)

Associated with attribute

In general, 47429007 | Associated with (attribute) | (http://snomed.info/id/47429007) should be avoided due to the
ambiguity which it conveys and the difficulty in applying this role consistently. Instead, “Due to” is used when there
is a strongly suspected or known causal relationship between the conditions; otherwise, the clinical conditions
should be recorded as separate concepts in the medical record.

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There are a couple of exceptions when the use of 47429007 | Associated with (attribute) | (http://snomed.info/id
/47429007) is appropriate :

1. General grouping concepts which aggregate more specific associations

e.g. 6211002 | Polyarthritis associated with another disorder (disorder) | (http://snomed.info/id/6211002)
subsumes two children
201972000 | Allergic arthritis of multiple sites (disorder) | (http://snomed.info/id/201972000) modeled with
42752001 | Due to (attribute) | (http://snomed.info/id/42752001) of 419076005 | Allergic reaction (disorder) | (
http://snomed.info/id/419076005)

422565003 | Post-infective polyarthritis (disorder) | (http://snomed.info/id/422565003) modeled with 255234002

| After (attribute) | (http://snomed.info/id/255234002) of 40733004 | Infectious disease (disorder) |
(http://snomed.info/id/40733004)

2. Device infections, i.e an infection of the tissue surrounding an implanted or inserted device, not due to the
device itself.
Associated with is used to associate the device with the infection.
3. Intolerance to substances, i.e the propensity of an adverse reaction to a substance to occur (other than
hypersensitivity or allergic or non-allergic hypersensitivity).
4. There is no intolerance process that serves as the value for Has realization.

Associated with is used to associate the intolerance to the substance.

Causative agent attribute

Many X caused by Y phenomena can be represented by 246075003 | Causative agent (attribute) | (http://snomed.info
/id/246075003). This approach is used where the causal factor is a material entity and the means of exposure
/introduction are not significant (if significant, then the causal factor is an event).

Caused by a substance or physical force

Default modeling pattern Default FSN construction

Assign the caused disorder as a supertype (or ensure that the caused Where X occurs due to exposure to a
disorder is present in the ancestor tree following classification) substance or physical force Y, construct
an FSN of the form X caused by Y
Assign the causal factor as the target of a Causative agent
relationship

Example:

291000119100 | Contact dermatitis caused by chemical (disorder) | (http://snomed.info/id/291000119100)

Legacy example (not to be repeated):

Laser-induced burn (disorder)

For all combined disorders where a cause can be either a disorder (eg, gallstones) or a material agent (eg, alcohol):
Model as caused by material agent if it is the direct cause.
For example,
445507008 | Inflammation of pancreas caused by alcohol (disorder) | (http://snomed.info/id/445507008)
Model as due to disorder if it is the indirect cause.
For example,

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 SNOMED CT Editorial Guide

Suggested change: Megaloblastic anemia caused by alcoholism (disorder) to Megaloblastic anemia due to
alcoholism (disorder)

Infectious complications
For infectious complications, use the 246075003 | Causative agent (attribute) | (http://snomed.info/id/246075003) if the
complication is the direct result of the presence of the infectious agent. Otherwise, use either due to or after or due
to and after X infection.

Infectious Complications

103611000119102 | Cirrhosis of liver due to hepatitis B Due to: 66071002 | Viral hepatitis type B (disorder)
(disorder) | (http://snomed.info/id/103611000119102) | (http://snomed.info/id/66071002)

195888009 | Proteus pneumonia (disorder) | (http://snomed. Caused by: 50517009 | Genus Proteus (organism)
info/id/195888009) | (http://snomed.info/id/50517009)

123949001 | Post-streptococcal reactive arthritis (disorder) | ( After: 302809008 | Streptococcus pyogenes

http://snomed.info/id/123949001) infection (disorder) | (http://snomed.info/id
/302809008)

Exception to naming convention for combined disorders

Disorder combination modeling

Disorder combination modeling:
Covers only combinations of two disorders. Frequently, combinations include more (including
syndromes).
Does not cover absent components or negation.
Does not cover cases where combination concepts are demonstrably classification-derived (This
limitation accepts that some content may be so obviously based on a class or category in a
classification that it would be undesirable to reinterpret its semantics).
The modeling approach may be difficult to apply in all cases of combined disorders; domain-
specific templates should be developed to ensure modeling consistency and accuracy.

Rather than the naming conventions described above, use the names that are accepted clinical parlance and that
represent specific pathophysiologic entities for some combined disorders,
For example,
10692681000119108 | Aspirin exacerbated respiratory disease (disorder) | (http://snomed.info/id
/10692681000119108), instead of Disorder of respiratory system exacerbated by aspirin (disorder)

Definition: nasal polyps, chronic rhino-sinusitis, asthma made worse by NSAIDs

724136006 | Diabetic mastopathy (disorder) | (http://snomed.info/id/724136006) instead of Disorder of breast due
to diabetes mellitus (disorder)
Definition: inflammation and fibrosis of breast due to diabetes mellitus

Loss of relationships by modeling with Due to attribute

There are certain combined disorders where a causal relationship may exist between the disorders, but using the
42752001 | Due to (attribute) | (http://snomed.info/id/42752001) may result in loss of important relationships that could
be stated in an axiom. Identifying these instances may prove challenging and may be best implemented at the time
of template creation for complex associations.

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For more information

SNOMED International website @ http://www.snomed.org/snomed-ct/learn-more.
Appendix B: Concept Models, Disorder Combinations

(See also, Appendix, Concept Models: Disorder Combinations)

Heuristics for Co-occurent Genomic Disorders

Germline chromosomal abnormality co-occurrent and causing disorder: 41040004 |Complete trisomy 21
syndrome (disorder)|
If the phenotype is always caused by a specific genotype, there is no need to include the cause in the FSN or clarify
with a Due to relationship.
Germline nucleotide sequence variant co-occurrent and causing disorder: 190905008 |Cystic fibrosis
(disorder)|
Modeling for germline mutations causing conditions, such as cystic fibrosis, should have co-occurrent mutations,
Occurrence = congenital, and Due to the mutation finding.
For example,
Cystic fibrosis co-occurrent and due to G542X mutation
Somatic NSV (NCBI structural variant) co-occurrent and poly-etiologic: BRAF V600E positive melanoma
Somatic mutations leading to cancer, such as malignant melanoma with BRAF V600E mutation, should have dual
supertypes, including the malignant disorder and the somatic mutation and Due to the associated somatic mutation
finding.
For example,
Melanoma co-occurrent and due to BRAF V600E mutation
Somatic IHC (immunohistochemical) finding co-occurrent but not etiologic: Estrogen-receptor status in
breast cancer
Somatic mutations which do not have a causative role in the development of a malignancy should be modeled as
Co-occurrent with two supertype concepts, but should not be modeled as due to the mutation.
For example,
Breast cancer co-occurrent with positive estrogen-receptor assay

Complication and Sequela Modeling

Complication and sequela attributes

Complications and sequelae are modeled using the Causal and Temporal attributes under the Associated with
attribute hierarchy:
Associated with (attribute)
Causative agent (attribute)
Due to (attribute)
Temporally related to (attribute)
During (attribute)
After (attribute)
A complication is a disorder caused by another disorder, procedure, or event which is not a natural progression or
expected outcome of its cause; temporally may be During and After the causative disorder, procedure, or event.

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When there is a causal relationship with the preceding disorder, procedure, or event, a sequela may also be a
complication i.e. the resultant disorder is not a natural progression or expected outcome of the preceding disorder,
procedure, or event.
A sequela, by definition, is a disorder that is a consequence, but not an unexpected outcome, that follows another
disorder, procedure, or event.

Complication and sequela relationships

Modeling
If a request is received for inclusion of a concept with an FSN containing complication or sequela and it is unclear
whether the relationship is causal and/or temporal, request additional information from the submitter.
A concept should always be modeled, primarily, according to its relationship to a procedure when the nature of
these relationships are clear.
Causation: Due to
Temporal relationship, i.e Temporally related to: During, After
For those occasions for which it is clear that an ensuing disorder starts during a procedure, but persists after
the procedure has been completed, both during and after attributes may be used in the model. After
This attribute is used to model concepts in which a clinical finding occurs after another clinical finding, procedure
or event. Neither asserting nor excluding a causal relationship, it instead emphasizes a sequence of events.
For example,
123948009 | Post-viral disorder (disorder) | (http://snomed.info/id/123948009) occurs After 34014006 | Viral disease
(disorder) | (http://snomed.info/id/34014006)
The words complication and sequela may or may not be part of an FSN.

Naming conventions for FSNs

Complication: X due to Y

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Sequela: X following Y
Complication & Sequela: X due to and following Y

Modeling
This modeling facilitates auto-classification. However, in SNOMED CT both 116223007 |
Complication (disorder) | (http://snomed.info/id/116223007) and 362977000 | Sequela (disorder) | (
http://snomed.info/id/362977000) are primitive, which means the relationship to these two concepts
has to be explicitly modeled with an IS_A relationship.
The semantic pattern Complication of implies Due to.
For new requests with the FSNs stating complication of, the FSN should be written as
complication due to and modeled accordingly.
There are legacy SNOMED CT terms for which there are duplicates, one with complication of
and one with complication due to. The duplicates will eventually be removed.

Complication and Sequela Allowable Relationships

Attribute IS A Sequela IS A Complication

Due to Possible/Allowable Necessarily true

During Not allowable Possible/allowable

After Necessarily true Possible/allowable

Types of complications and sequelae

The three types are as follows:
Only the cause is specified
Only a temporal relationship is specified
Both a cause and a temporal relationship to the cause are specified

Types of Complications and Sequelae

Complications

Type Disorder / Disorder Modeling Notes

Cause only 11307961000119106 | Due to Due to can be used to assert causality, at

Pathological fracture of any point in a causal chain, between a
X due to Y
pelvis due to neoplastic condition or procedure and another
disease (disorder) | ( Create an IS A resultant condition, when there is no
http://snomed.info/id relationship to explicit temporal relationship
/11307961000119106) 116223007 |
Complication
(disorder) | (
http://snomed.info/id
/116223007)

NA Before

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Types of Complications and Sequelae

X before Y
Temporal Use to model pre-procedure complications
only (e.g, preoperative complication), without
causal relationships
Model with Before, but without assigning a
parent of Complication or a causal
relationship

These concepts are During Use to model a disorder that occurs during
modeled with the a procedure (e.g, intraoperative
X during Y
Combined disorder complication), but without a causal
guidelines. relationship
O nly use when understood in the FSN (e.g.
intraoperative complication or X
complication during Y

Causal + These concepts are Due to and During Use to model a disorder that occurs during
Temporal modeled with the a procedure (e.g. intraoperative
X due to and during Y
Combined disorder complication), with a causal relationship
guidelines.
Both a cause and a temporal relationship to
the cause are specified
A Due to and During relationship, makes
the concept analogous to the use of the A
fter relationship

Due to and After Use to model a disorder that occurs after a

disorder or procedure (e.g. postoperative
X due to and
complication), with a causal relationship
following Y
Both a cause and a temporal relationship to
the cause are specified

Sequelae

Type Disorder / Disorder Modeling Notes

Temporal NA After Use to model a disorder that occurs after a

only procedure
X following Y
Does not assert or exclude a causal
Create an IS_A
relationship; instead it emphasizes a
relationship to
sequence of events ( e.g. every post-viral
362977000 | Sequela
disorder occurs after a viral disease)
(disorder) | (
http://snomed.info/id A disorder that follows a procedure is a
/362977000) sequela, unless the disorder and procedure
are arbitrarily associated

Causal + 230691006 | Due to and After Use to model a disorder that occurs after a
Temporal Cerebrovascular disorder or procedure (e.g. postoperative
X due to and
accident due to complication), with a causal relationship
following Y
occlusion of cerebral Both a cause and a temporal relationship to
artery (disorder) | ( the cause are specified
http://snomed.info/id
/230691006)

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Sequelae and Late Effects

ICD uses the phrase late effects, which is equivalent to sequela. Thus it should be modeled with after (and due to if
there is a causal relationship) and with an IS A relationship to 362977000 | Sequela (disorder) | (http://snomed.info/id
/362977000).

Naming conventions for sequelae

FSN: Disorder X [due to and] following <<disorder /<<procedure /<event
PT: Disorder X [due to and] following <<disorder /<<procedure /<event
SYN: [Disorder X as a] Sequela of <<disorder /<<procedure /<event
SYN: [Disorder X as a] Late effect of <<disorder /<<procedure /<event
For example,
Disorder due to and following another disorder (disorder)
Disorder due to and following meningitis (disorder)
Disorder due to and following procedure (disorder)

Surgical complications, sequelae, and late effects

Not all surgical sequelae are complications of surgery, but rather expected late effects.
Postoperative complications are complications following surgery, but not necessarily due to the surgery and, thus,
are modeled only with an after relationship.
Naming conventions for surgical sequelae (temporal only)
FSN: Disorder X following <<387713003 |Surgical procedure (procedure)
PT: Disorder X following <<387713003 |Surgical procedure (procedure)
For example,
Contraction of eye socket following enucleation (disorder)
Scar following surgery (disorder)
Naming conventions for postoperative complications (temporal only)
FSN: Postoperative X (disorder)
PT: Postoperative X
For example,
Postoperative infection (disorder)
Postoperative ileus (disorder)
Postoperative hypothyroidism (disorder)
Naming conventions for postoperative complications due to surgery
Complications that occur after surgery and are modeled with a parent of 116223007 |Complication (disorder)| and
with | after | (http://snomed.org/fictid#) | surgical procedure | (http://snomed.org/fictid#).
FSN: Disorder X due to [and following] << 387713003 |Surgical procedure (procedure)
PT: Disorder X due to [and following] << 387713003 |Surgical procedure (procedure)|
For example,
Encephalopathy due to and following cardiopulmonary bypass (disorder)
Cataract lens fragments in vitreous of eye due to and following cataract surgery (disorder)
Disorder due to and following breast reduction (disorder)

Modeling for transplantation rejection vs. failure

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Modeling for transplantation rejection vs. failure

Transplantation rejection
IS A = disease
clinical course = acute/chronic etc.
after = transplantation of x (procedure)
finding site = transplanted x body structure
Transplantation failure
IS A = complication
clinical course = acute/chronic etc.
after = transplantation of x (procedure)
finding site = transplanted x body structure

Exceptions
Perioperative complications
Peri-operative complications refer to complications temporally related to a surgical procedure. They include pre-
operative, intra-operative and post-operative complications and are modeled with a parent of | complication | (
http://snomed.org/fictid#)and a relationship consisting of | temporally related to | (http://snomed.org/fictid#) or an
appropriate subtype with a value of 387713003 |Surgical procedure (procedure)|.
Such complications do not necessarily imply a causal relationship to the surgery itself as they may be related to any
disorder, event or procedure occurring prior, during and/or after surgery. For this reason, perioperative
complications do not have a stated causal relationship unless an underlying cause is clearly stated in the FSN.
Preoperative complications
A preoperative complication can occur prior to surgery. Strictly, it is a disorder that complicates the procedure
rather than being a complication of that procedure. A preoperative complication might be considered to be a
disorder that exists prior to surgery that adversely affects the surgery or that results in an intra-operative or post-
operative complication. Such concepts should be modeled using the | before | (http://snomed.org/fictid#), but not
assigned a parent of complication or a causative relationship.
For example,
| preoperative hyponatremia | (http://snomed.org/fictid#)
| preoperative anxiety | (http://snomed.org/fictid#)

Determining the causal relationship

Most combined disorders have a direct or indirect causal relationship. Concepts containing the words following,
after, post, or sequela in the FSN, and/or are modeled using the after attribute, should be considered to be sequela,
and usually complications as well.

Environment and Geographical Location*

Definition Examples

Environment: types of environments 398156002 | Medical or surgical floor (environment) |

(http://snomed.info/id/398156002)
Location: named locations such as
countries, states, or regions 223565009 | Nigeria (geographic location) | (
http://snomed.info/id/223565009)

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 SNOMED CT Editorial Guide

Event

Definition Examples

Occurrences impacting health or health care; not 242039002 | Abuse of partner (event) | (
procedures or interventions http://snomed.info/id/242039002)

405621004 | Tracheal intubation event (event) | (

http://snomed.info/id/405621004)

Event Attributes Summary

When authoring in this domain, these are the approved attributes and allowable ranges. They are from the Human
Readable Concept Model (HRCM). HRCM 2020-01-31

Domain Information for 272379006 | Event (event) | (http://snomed.info/id/272379006)

Domain Constraint << 272379006 | Event (event) | (http://snomed.info/id/272379006)

Parent Domain -

Proximal Primitive << 272379006 | Event (event) | (http://snomed.info/id/272379006)

Constraint

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 272379006 | Event (event) | (http://snomed.info/id/272379006)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

255234002 | After (attribute) | ( 1 0..* 0..1 << 404684003 | Clinical finding

http://snomed.info/id/255234002) (finding) | (http://snomed.info/id
/404684003) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002) OR
<< 272379006 | Event (event) | (
http://snomed.info/id/272379006)

47429007 | Associated with 1 0..* 0..* << 404684003 | Clinical finding

(attribute) | (http://snomed.info/id (finding) | (http://snomed.info/id
/47429007) /404684003) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002) OR
<< 272379006 | Event (event) | (
http://snomed.info/id/272379006) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR
<< 105590001 | Substance
(substance) | (http://snomed.info/id

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 SNOMED CT Editorial Guide

/105590001) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 78621006 | Physical force
(physical force) | (http://snomed.info/id
/78621006)

288556008 | Before (attribute) | ( 1 0..* 0..1 << 71388002 | Procedure (procedure)

http://snomed.info/id/288556008) | (http://snomed.info/id/71388002)

246075003 | Causative agent 1 0..* 0..1 << 410607006 | Organism (organism)

(attribute) | (http://snomed.info/id | (http://snomed.info/id/410607006) OR
/246075003) << 105590001 | Substance
(substance) | (http://snomed.info/id
/105590001) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 78621006 | Physical force
(physical force) | (http://snomed.info/id
/78621006)

42752001 | Due to (attribute) | ( 1 0..* 0..1 << 404684003 | Clinical finding

http://snomed.info/id/42752001) (finding) | (http://snomed.info/id
/404684003) OR
<< 272379006 | Event (event) | (
http://snomed.info/id/272379006) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002)

371881003 | During (attribute) | ( 1 0..* 0..1 << 71388002 | Procedure (procedure)

http://snomed.info/id/371881003) | (http://snomed.info/id/71388002)

246454002 | Occurrence 1 0..* 0..1 << 282032007 | Periods of life

(attribute) | (http://snomed.info/id (qualifier value) | (http://snomed.info/id
/246454002) /282032007)

726633004 | Temporally related 1 0..* 0..* << 404684003 | Clinical finding

to (attribute) | (http://snomed.info (finding) | (http://snomed.info/id
/id/726633004) /404684003) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002)

Authoring guidelines for the use of attributes in the Event hierarchy are being established.

Event Modeling
When modeling an event, be sure to model the event itself and not the outcome of an event. The outcome of an
event would be a finding or a disorder.

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Event attributes
Under review at this time.

Allowed ranges
The allowed ranges will not prevent some incorrect modeling. Some allowed attributes have not yet
been used for modeling in the Event domain. The planned QI project will review the modeling to ensure
consistency of use the allowed attributes.

Modeling
Vaccine-related overdose
For the January 2020 Release, vaccine-related overdose concepts in the Clinical Finding/Disorder
hierarchy were inactivated. They were replaced with excessive dose concepts in the Event
hierarchy.
When authoring, determine whether the concept describes an overdose, a disorder, or the
administration or ingestion of an excessive dose, an event.

Observable Entity

Definition Examples

Information about a quality/property to be observed and 416540001 | Calcium deposit observable

how it will be observed (observable entity) | (http://snomed.info/id
/416540001)

276885007 | Core body temperature

(observable entity) | (http://snomed.info/id
/276885007)

Observable Entity vs. Evaluation Procedure

The observable entity and evaluation procedure hierarchies have some of the same attributes. There is not and
should not be a one-to-one correspondence between the two hierarchies.
At this time, SNOMED CT contains some concepts in the evaluation procedure hierarchy which logically belong in
the observable entity hierarchy. This is a legacy problem that continues to cause confusion. These concepts will
move to the observable entity hierarchy as part of the QI project in the future. In addition, if we identify existing
duplicate concepts between the two hierarchies, this will also be corrected. Concepts will not be duplicated
between the observable entity hierarchy and procedure hierarchy, and requests for such will not be added.
While some users have indicated they want to use a procedure concept for ordering a test and an observable
concept for reporting the result, this is not an acceptable use case. An evaluation procedure being ordered implies
that there is an expectation that a value, in association with the ordered procedure will be provided. Evaluation
procedures, for all intents and purposes, are observables with another semantic tag. The nature of their top level
parent (Evaluation procedure) implies that they require a value in order to be assessed. Thus they can be used
equivalently with observables.
As for the progression of the completion of an assessment, that is related to the state diagram (i.e., status) of the
progression of a procedure and should not be precoordinated, but handled by the information system in which
orders are processed (it is dynamic, not static). The information system should be able to capture the status of a
procedure (e.g., ordered, in process, completed). We would not expect the terminology to pre-coordinate this.

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 SNOMED CT Editorial Guide

As an example, LOINC recognizes that there are three different aspects to an observable: 1) those that can serve as
both an order and an observation (e.g. blood glucose level); 2) those that can be ordered but not directly resulted (e.
g. urinalysis, which is a convenience order for multiple individual observations on urine); and 3) those that can only
be resulted and not directly ordered (usually part of an automated system, such as computation of MCHC in
hematology). LOINC assigns this aspect with an attribute value. It is not one of the six main LOINC parts typically
visible to users, however it is included in the LOINC database.

Use of Observable Entities

Observables entities may be used to:
Code elements on a checklist or assign values to elements.
For example, color of nail is an observable entity. Gray nails is a finding.
Code headers on a template
For example, the observable entity, gender, may be used to code a section of a template titled gender. The user
would choose masculine, feminine, transgender, etc. which would then constitute a finding such as 703117000 |
Masculine gender (finding) | (http://snomed.info/id/703117000).

Types of Observable Entities

There are four general types of observable entities for use in health care. Each has different representation
requirements and patterns, i.e. the set of attributes will vary.
Quality. A characteristic, feature, or property that is inherent in someone or something.
For example, mass of a person, temperature of internal organs, concentration of sodium in plasma, angle of a joint
Disposition. A characteristic or feature that is not always realized in full.
For example, antibiotic susceptibility of a certain population
Function. The ability of a person, some part of a person, or a thing to perform activities or realize processes.
For example, ability to walk
Process. A process or outcome of a process
For example, secretion rate, heart rate, respiratory rate

Observable Entity Attributes Summary

When authoring in this domain, these are the approved attributes and allowable ranges. They are from the Human
Readable Concept Model (HRCM). HRCM 2020-01-31

Domain Information for 363787002 | Observable entity (observable entity) | (http://snomed.info/id/363787002)

Domain Constraint << 363787002 | Observable entity (observable entity) | (http://snomed.info/id/363787002)

Parent Domain -

Proximal Primitive << 363787002 | Observable entity (observable entity) | (http://snomed.info/id/363787002)

Constraint

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 363787002 | Observable entity (observable entity) | (http://snomed.info/id
/363787002)

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Attribute Grouped Cardinality In Group Range Constraint

Cardinality

704321009 | Characterizes 1 0..* 0..1 << 719982003 | Process (qualifier

(attribute) | (http://snomed.info/id value) | (http://snomed.info/id/719982003)
/704321009) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002)

246093002 | Component 1 0..* 0..1 << 123037004 | Body structure (body

(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/246093002) /123037004) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR
<< 105590001 | Substance
(substance) | (http://snomed.info/id
/105590001) OR
<< 123038009 | Specimen (specimen)
| (http://snomed.info/id/123038009) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005) OR
<< 419891008 | Record artifact
(record artifact) | (http://snomed.info/id
/419891008)

704327008 | Direct site 1 0..* 0..1 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/704327008) /123037004) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR
<< 105590001 | Substance
(substance) | (http://snomed.info/id
/105590001) OR
<< 123038009 | Specimen (specimen)
| (http://snomed.info/id/123038009) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005) OR
<< 419891008 | Record artifact
(record artifact) | (http://snomed.info/id
/419891008)

719722006 | Has realization 1 0..* 0..1 << 719982003 | Process (qualifier

(attribute) | (http://snomed.info/id value) | (http://snomed.info/id/719982003)
/719722006)

718497002 | Inherent location 1 0..* 0..1 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/718497002) /123037004) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR

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 SNOMED CT Editorial Guide

<< 105590001 | Substance

(substance) | (http://snomed.info/id
/105590001) OR
<< 123038009 | Specimen (specimen)
| (http://snomed.info/id/123038009) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005) OR
<< 419891008 | Record artifact
(record artifact) | (http://snomed.info/id
/419891008)

704319004 | Inheres in 1 0..* 0..1 << 123037004 | Body structure (body

(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/704319004) /123037004) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR
<< 105590001 | Substance
(substance) | (http://snomed.info/id
/105590001) OR
<< 123038009 | Specimen (specimen)
| (http://snomed.info/id/123038009) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005) OR
<< 419891008 | Record artifact
(record artifact) | (http://snomed.info/id
/419891008) OR
<< 125676002 | Person (person) | (
http://snomed.info/id/125676002)

704326004 | Precondition 1 0..* 0..1 << 404684003 | Clinical finding

(attribute) | (http://snomed.info/id (finding) | (http://snomed.info/id
/704326004) /404684003) OR
<< 703763000 | Precondition value
(qualifier value) | (http://snomed.info/id
/703763000) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002)

405815000 | Procedure device 1 0..* 0..1 << 49062001 | Device (physical

(attribute) | (http://snomed.info/id object) | (http://snomed.info/id/49062001)
/405815000)

704322002 | Process agent 1 0..* 0..1 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/704322002) /123037004) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 373873005 | Pharmaceutical /

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 SNOMED CT Editorial Guide

biologic product (product) | (

http://snomed.info/id/373873005) OR
<< 105590001 | Substance | (
http://snomed.info/id/105590001)

704323007 | Process duration 1 0..1 0..1 << 7389001 | Time frame (qualifier
(attribute) | (http://snomed.info/id value) | (http://snomed.info/id/7389001)
/704323007)

704324001 | Process output 1 0..* 0..1 << 105590001 | Substance

(attribute) | (http://snomed.info/id (substance) | (http://snomed.info/id
/704324001) /105590001) OR
<< 719982003 | Process (qualifier
value) | (http://snomed.info/id/719982003)

370130000 | Property (attribute) 1 0..1 0..1 << 118598001 | Property of

| (http://snomed.info/id/370130000) measurement (qualifier value) | (
http://snomed.info/id/118598001)

704325000 | Relative to 1 0..* 0..1 << 123037004 | Body structure (body

(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/704325000) /123037004) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR
<< 105590001 | Substance
(substance) | (http://snomed.info/id
/105590001) OR
<< 123038009 | Specimen (specimen)
| (http://snomed.info/id/123038009) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005) OR
<< 419891008 | Record artifact
(record artifact) | (http://snomed.info/id
/419891008)

719715003 | Relative to part of 1 0..* 0..1 << 123037004 | Body structure (body
(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/719715003) /123037004) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR
<< 105590001 | Substance
(substance) | (http://snomed.info/id
/105590001) OR
<< 123038009 | Specimen (specimen)
| (http://snomed.info/id/123038009) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005) OR
<< 419891008 | Record artifact
(record artifact) | (http://snomed.info/id
/419891008)

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 SNOMED CT Editorial Guide

370132008 | Scale type 1 0..1 0..1 << 30766002 | Quantitative | (

(attribute) | (http://snomed.info/id http://snomed.info/id/30766002) OR
/370132008) << 26716007 | Qualitative | (
http://snomed.info/id/26716007) OR
<< 117363000 | Ordinal value | (
http://snomed.info/id/117363000) OR
<< 117365007 | Ordinal or quantitative
value | (http://snomed.info/id/117365007)
OR
<< 117362005 | Nominal value | (
http://snomed.info/id/117362005) OR
<< 117364006 | Narrative value | (
http://snomed.info/id/117364006) OR
<< 117444000 | Text value | (
http://snomed.info/id/117444000)

246501002 | Technique 1 0..* 0..1 << 272394005 | Technique (qualifier

(attribute) | (http://snomed.info/id value) | (http://snomed.info/id/272394005)
/246501002) OR
<< 273249006 | Assessment scales
(assessment scale) | (http://snomed.info
/id/273249006)

370134009 | Time aspect 1 0..1 0..1 << 7389001 | Time frame (qualifier
(attribute) | (http://snomed.info/id value) | (http://snomed.info/id/7389001)
/370134009)

704320005 | Towards (attribute) 1 0..* 0..1 << 123037004 | Body structure (body
| (http://snomed.info/id/704320005) structure) | (http://snomed.info/id
/123037004) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR
<< 105590001 | Substance
(substance) | (http://snomed.info/id
/105590001) OR
<< 123038009 | Specimen (specimen)
| (http://snomed.info/id/123038009) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005) OR
<< 419891008 | Record artifact
(record artifact) | (http://snomed.info/id
/419891008)

246514001 | Units (attribute) | ( 1 0..1 0..1 < 767524001 | Unit of measure

http://snomed.info/id/246514001) (qualifier value) | (http://snomed.info/id
/767524001)

424226004 | Using device 1 0..* 0..1 << 49062001 | Device (physical

(attribute) | (http://snomed.info/id object) | (http://snomed.info/id/49062001)
/424226004)

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Observable Entity Defining Attributes

The observable model has been scarcely implemented in current SNOMED content, so the following defining
attributes that correspond to the Observable Entity Attributes Summary table will have many hypothetical examples.

Characterizes
This attribute specifies the process which the property describes, and on which the property (of this observable)
depends. The process can be very general (e.g. excretion).
For example,
Mass concentration ratio of silver to creatinine in 24-hour urine (observable entity) has 704321009 |
Characterizes (attribute) | (http://snomed.info/id/704321009) of excretion process
Estimated intake of potassium in 24 hours (observable entity)| has a 704321009 |Characterizes (attribute)| of
administration of substance

Component
This attribute is used to specify the numerator of a relational property types, e.g. ratio, concentration.
For example,
Arbitrary concentration of Varicella-Zoster virus (observable entity) has the 246093002 | Component
(attribute) | (http://snomed.info/id/246093002) of Human herpesvirus 3

Direct site
This attribute is used to specify the entity on which the observation is directly made. It may also be used when the
observation is indirect, i.e. when a direct observation cannot be done.
For example,
415974002 | Core body temperature measured at tympanic membrane (observable entity) | (http://snomed.info
/id/415974002) has the 704327008 | Direct site (attribute) | (http://snomed.info/id/704327008) of tympanic
membrane structure

Has realization
This attribute is used to specify the process or activity that is the consequence of realization of the function.
For example,
282097004 | Ability to walk (observable entity) | (http://snomed.info/id/282097004) 719722006 | Has realization
(attribute) | (http://snomed.info/id/719722006) of walking

Inherent location
This attribute is used to specify a body site or other location of the independent continuant in which the property
exists.
For example,
DNA taxon of Mycobacterium from bronchial secretions (observable entity) has 718497002 | Inherent location
(attribute) | (http://snomed.info/id/718497002) of bronchus

Inheres in
This attribute specifies the independent continuant in which the quality exists and on which the dependent quality
(of this observable) depends.
For example,
Volume of 24-hour urine sample (observable entity) has 704319004 | Inheres in (attribute) | (http://snomed.info
/id/704319004) of 24 hour urine sample

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 SNOMED CT Editorial Guide

Precondition
This attribute is used to specify body state, timing, challenges, or other situations that must be true of the entity to
be observed.
For example,
Plasma creatinine concentration 7 days post challenge (observable entity) has a Precondition of 7 days post
challenge
163033001 | Lying blood pressure (observable entity) | (http://snomed.info/id/163033001) has a 704326004 |
Precondition (attribute) | (http://snomed.info/id/704326004) of recumbent body position

Procedure device
This attribute is used to model devices associated with a procedure. This attribute is used to define high-level,
general concepts that aggregate procedures according to the device involved.

Process agent
This attribute is used to specify the continuant (e.g. body structure or organism) that is causally active in the process
on which the property depends. It may refine the meaning of the process named as the value of 704321009 |
Characterizes (attribute) | (http://snomed.info/id/704321009), or it may simply repeat the meaning that is already there.
The process agent can be left unspecified.
For example,
Substance rate of secretion of somatotropin by pituitary following clonidine per os (observable entity) has the
704322002 | Process agent (attribute) | (http://snomed.info/id/704322002) of pituitary gland.

Process agent and has agent

704322002 | Process agent (attribute) | (http://snomed.info/id/704322002) appears to have the same
meaning as Has agent in the Open Biological and Biomedical Ontology (OBO) Relations Ontology.

Process duration
This attribute specifies the duration of the process characterized by the observable property type.
For example,
Mass rate of excretion of cortisone in 24 hour urine (observable entity) has the 704323007 | Process duration
(attribute) | (http://snomed.info/id/704323007) of 24 hours

Process output
This attribute is used to specify the substance or process produced by the process characterized by the observable
property type.
For example,
Substance rate of excretion of pregnanediol in micromoles per day (observable entity) has a 704324001 |
Process output (attribute) | (http://snomed.info/id/704324001) of pregnanediol
Estimated intake of iron in 24 hours (observable entity)| has a 704324001 | Process output (attribute) | (
http://snomed.info/id/704324001) of iron

Property
This attribute is used to specify the type of inherent quality or process to be observed. Its values are abstract types
of quality (length, odor, concentration) or abstract types of process features (rate, speed).
For example,

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 SNOMED CT Editorial Guide

Blood glucose mass concentration (observable entity) has the 370130000 | Property (attribute) | (http://snomed.
info/id/370130000) of mass concentration

Relative to
This attribute is used to specify the denominator of a relational property type, e.g. a ratio or proportion.
For example,
Urine alpha aminobutyrate to creatinine ratio (observable entity) has 704325000 | Relative to (attribute) | (
http://snomed.info/id/704325000) creatinine

Neutrophils per 100 leukocytes in blood (observable entity) has 704325000 | Relative to (attribute) | (
http://snomed.info/id/704325000) population of all leukocytes in portion of fluid

Relative to part of
This attribute is used to specify the denominator of a relative relational property, su ch as a ratio of ratios.
For example,
Relative substance concentration of cerebrospinal fluid IgM to plasma IgM (observable entity) has 719715003 |
Relative to part of (attribute) | (http://snomed.info/id/719715003) of plasma

Scale Type
This attribute is used to specify the scale of the result of an observation or a diagnostic test (i.e., quantitative,
qualitative, semi-quantitative).

When defining observable entities for the international release, the | Scale type (attribute) | (http://snomed.
org/fictid#) will not be used. Extensions are permitted to add specific subtypes of observable entities that
include the | Scale type (attribute) | (http://snomed.org/fictid#), if desired.

Technique
This attribute is used to specify the systematic method of a procedure used to accomplish a specific activity.
For example,
Presence of Brucella abortus antibody in serum by latex agglutination (observable entity) has the 246501002 |
Technique (attribute) | (http://snomed.info/id/246501002) of latex agglutination test technique

Time Aspect
This attribute is used to specify the timing of an observation.
For example,
Substance concentration of acetone in urine (observable entity) has the 370134009 | Time aspect (attribute) | (
http://snomed.info/id/370134009) of Single point in time

Towards
This attribute is used to specify a disposition, what the disposition is towards, i.e. a specific triggering agent, or more
generally, participant in the realization of the disposition.
For example,
Quantitative susceptibility of Pseudomonas aeruginosa to amikacin in microbial isolate by disk diffusion
(observable entity) has 704320005 | Towards (attribute) | (http://snomed.info/id/704320005) of amikacin

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 SNOMED CT Editorial Guide

Units
This attribute is used to specify the units used in assigning a value to an observation.
For example,
Basophils per 100 leukocytes (observable entity) has the 246514001 | Units (attribute) | (http://snomed.info/id
/246514001) of percentage

Using device
This attribute is used to specify the instrument or equipment utilized to execute an action. Using device is
appropriate when the device is actually used to carry out the action that is the focus of the procedure.
For example,
415921007 | Temperature of forehead using skin strip thermometer (observable entity) | (http://snomed.info/id
/415921007) has 424226004 | Using device (attribute) | (http://snomed.info/id/424226004) of skin strip
thermometer

Observable Entity Modeling

When observable entity concepts have not been given a value, they behave like procedures, with respect to the
concept model for context.
When observable entities have been given a value, they behave like clinical findings, with respect to the concept
model for context.

Modeling
The observable entity model has been implemented in limited content areas in SNOMED CT thus far. 167
physiological measurement observable entity concepts (body temperature, respiratory rate, heart rate, blood
pressure) have been modeled. Additional concepts using observable entity attributes have been defined since the
January 2020 release. The majority of the changes are related to nutritional intake (e.g., food intake, vitamin intake,
fasting pattern) observable entity concepts. Vital sign (observable entity) has been inactivated since it could not be
universally defined.
Susceptibility observables should be modeled in accordance with the template specified here .

Test Observable Entity Naming Conventions

Naming conventions for the fully specified name (FSN) for observable entities and for naming evaluation procedures
or observable entities that are submitted with names from the IFCC-IUPAC NPU systems are as follows:
General naming pattern: Property, Component, Direct Site
First: Property
Property (the property type of the observable) is named first, when possible.
Modifier: Scale Method.
Scale Method refines the Property, and, therefore, precedes the action in the naming order.
(Scale Method, Property)
Naming pattern: (Scale Method, Property), Component, Direct Site
Second: Component
Property is named first, followed by the entity that is the value of Component, when possible.
Third: Direct Site
Modifier: Time aspect. Time aspect provides information about the direct site and precedes it in the
naming order. (Time aspect, Direct Site)
For example,
416125006 | Concentration of hemoglobin in erythrocyte (observable entity) | (http://snomed.info/id/416125006)

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 SNOMED CT Editorial Guide

Modeling: Screening measurements

Measurements done by screening should be specified with by screening method added at the end of the
description.

Observable Entity and Microbiology Test Results

When microbiology laboratory results are encoded, it is important to be aware of the context provided by the
observation, i.e. the test performed and, therefore, the implied meaning of the result value, i.e. the organism.
For example, the combination of Logical Observation Identifiers Names and Codes (LOINC) for the lab test and
SNOMED CT for the organism, provides a unique and specific meaning:
LOINC provides microbiology reporting codes with attributes including the property through the use of PRID
(presence or identity) and the scale through the use of NOM (nominal or categorical response that does not
have a natural ordering) as the result value (typically the name of organism).
Use of organism concepts in combination with such LOINC codes implies that a specific organism is seen,
detected, identified, isolated, or present.

Organism
On its own, an organism concept can only indicate the definition of that organism. Its detection or
presence can only be implied when it is paired with other information that may come from the electronic
health application and/or from the LOINC observation.

Organism X or organism Y
Use organism X or organism Y w hen a laboratory report indicates a single isolate is assumed, but the lab is unable
(for any reason) to differentiate the result instance.
For example,
703015006 | Human coxsackievirus or human echovirus (finding) | (http://snomed.info/id/703015006)

Organism X, not organism Y

Use organism X, not organism Y when a laboratory report indicates a class of organisms described by the exclusion
of specific Linnaean or non-Linnaean classes. These concepts are found in the organism hierarchy (based on
reasonable use cases to avoid a combinatorial explosion). They are a primitive super class, in between the species or
species subtype.
For example,
115407004 | Haemophilus influenzae, not b (organism) | (http://snomed.info/id/115407004)

Genus X, not species Y and not species Z

Use Genus X, not species Y and not species Z when a laboratory report indicates a species of Genus X and confirms
that it is not species Y, nor species Z. E.g. Bacillus species, not Bacillus anthracis and not Bacillus cereus (organism).
Use this naming convention only with Genus, species, and subspecies levels of the hierarchy.

Untypable organisms
Laboratory reports and journal articles may include an organism that could not be serotyped, e.g. E. coli, untypable.
The requests for such concepts are declined due to ambiguity. Instead, use the closest taxonomic level in the
hierarchy.

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 SNOMED CT Editorial Guide

Presumptive values
Laboratory findings may be reported with a status of preliminary, presumptive, provisional, etc. These typically
cover reportable or notifiable lab values. The status of a report is different from the result; it is part of the electronic
health application model/message. The requests for such concepts are declined as they are ambiguous and subject
to limitless combinations.

Concepts with presumptive values

Existing concepts with presumptive values are undergoing review for inactivation.

Mixed Organism
Some laboratories report findings indicating a mixed population of bacteria from several classes, e.g. mixed
anaerobic Gram negative bacilli. The request for such a concept is added as a clinical finding. The actual organism is
unknown, however there is a result, although more general.

Reporting Negative and Positive Results

Laboratories perform and report on specific tests to identify the absence, as well as the presence, of a particular
pathogenic organism. Laboratories typically report negative result values, such as X not seen, X not detected, X not
isolated, and no X seen (or identified or isolated) and positive results as X seen, X detected, and X isolated. The
following tables includes the acceptable modeling for negative and positive results.

Microbiology Tests: Negative and Positive Values

Lab test Value

General culture (scale = nominal) No X isolated (finding)

X (organism)

Specific culture Not isolated (qualifier value)

Isolated (qualifier value)

General microscopic testing (Scale = Nominal) No X seen (finding)

X (organism)

Specific microscopic testing Not seen (qualifier value)

Present (qualifier value)

Serologic, DNA or other organism specific test Not detected (qualifier value)
Detected (qualifier value)
Rationale: Almost all of these tests are organism-
specific

Microbiology Tests: Examples of Negative and Positive Values

Test Category Lab observation (lab test) LOINC Result values (lab result) SNOMED CT

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 SNOMED CT Editorial Guide

Microbiology Tests: Examples of Negative and Positive Values

General culture 11475-1 - Microorganism X Culture (where X Valid value

represents no specific system/specimen is part of
168204005 | Salmonella not isolated
the concept)
(finding) | (http://snomed.info/id
/168204005)

27268008 | Genus Salmonella

(organism) | (http://snomed.info/id
/27268008)

Invalid value
Not isolated
Isolated

Organism-specific 48741-3 Bordetella pertussis; Nasopharynx; Valid value

culture Culture
264887000 | Not isolated (qualifier
value) | (http://snomed.info/id
/264887000)

46651001 | Isolated (qualifier value) | (

http://snomed.info/id/46651001)

Invalid value
Bordetella pertussis not isolated
Bordetella pertussis isolated

10635-1 - Acanthamoeba Eye Culture Valid value

264887000 | Not isolated (qualifier
value) | (http://snomed.info/id
/264887000)

46651001 | Isolated (qualifier value) | (

http://snomed.info/id/46651001)

Invalid value
No Acanthamoeba isolated
Acanthamoeba isolated

Specific microscopic 14369-3 - Yeast Cervix Ql Wet Prep Valid value

testing
47492008 | Not seen (qualifier value)
| (http://snomed.info/id/47492008)
52101004 | Present (qualifier value) | (
http://snomed.info/id/52101004)

Invalid value
No yeast seen
Yeast seen

Serologic and DNA 35727-7 - Chlamydia species DNA; Urethra; PCR Valid value
testing /NAAT
260415000 | Not detected (qualifier
value) | (http://snomed.info/id
/260415000)

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 SNOMED CT Editorial Guide

Microbiology Tests: Examples of Negative and Positive Values

260373001 | Detected (qualifier

value) | (http://snomed.info/id/260373001
)

Invalid value
No Chlamydia detected
Chlamydia detected

Relationship between Observable Entities and NPU codes

Nomenclature, Properties, and Units (NPU) is a coding system and terminology for identification and
communication of examination results from clinical laboratories. Please see their website for more information:
http://www.npu-terminology.org/ (http://www.npu-terminology.org/%C2%A0for).
Logically there is a relationship between NPU and SNOMED CT observable entities. A pilot project examined
overlaps and possible alignment; further work may be done. However, there is no formally maintained SNOMED CT
documentation on this alignment.

Representing LOINC Terms with the SNOMED CT Observable Entity Model

Logical Observation Identifiers Names and Codes (LOINC) terms are defined using the Observable Entity model in
SNOMED CT as produced in the LOINC - SNOMED CT Cooperation Project releases.
The project release documentation contains information about how LOINC terms and parts are aligned with
SNOMED CT concepts using the model.

For more information

SNOMED CT July 2017 LOINC - SNOMED CT Cooperative package Production release - RF2 Release notes

Nutritional intake observable entities

Naming conventions for estimated and measured intake or nutrient administration, in aggregate or as a portion of
intake via a specified route (ie, oral, gastroenteral [enteral nutrition], parenteral nutrition, and via intravenous fluids),
is as follows:
FSN: [technique] quantity of intake of [substance] via [route] in [timeframe] (observable entity)
SYN: [technique] quantity of intake of [substance] via [route] in [timeframe]
See the specific template here.
For example,
789106008 | Estimated quantity of intake of phosphorous in 24 hours (observable entity) | (http://snomed.info/id
/789106008)

FSN: Estimated quantity of intake of phosphorous in 24 hours (observable entity)

PT: Estimated quantity of intake of phosphorous in 24 hours

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Figure 1: Stated view of 789106008 |Estimated quantity of intake of phosphorous in 24 hours (observable entity)|

Dietary
"Dietary" is considered ambiguous and should not be included in SNOMED CT. Existing content that
includes "dietary" will be considered for inactivation.

Organism*

Definition Examples

Organisms of significance to human medicine 3265006 | Genus Candida (organism) | (

http://snomed.info/id/3265006)

710877000 | Beta lactam resistant bacteria

(organism) | (http://snomed.info/id/710877000
)

Organism concepts
Organism concepts are used:
In modeling cause of disease
To document the cause of reportable or notifiable diseases
In evidence-based infectious disease protocols, e.g. in clinical decision-support systems

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Organisms with qualifiers

Intrinsic qualifiers
If a qualifier is an intrinsic part of an organism, it belongs in the organism hierarchy and is modeled
accordingly. Intrinsic should be interpreted as a characteristic that is inherent in the organism (e.g. Gram-
positive), as opposed to a context-dependent characteristic (e.g. some uses of intracellular).

When modeling organisms with qualifiers, the qualifier should be placed in front of the organism name.

Morphology qualifiers
For example, a non-Linnaean class of bacteria described by morphology
8745002 | Gram-positive bacterium (organism) | (http://snomed.info/id/8745002)
416983001 | Helical Gram-negative bacillus (organism) | (http://snomed.info/id/416983001)

Physiology qualifiers
For example, a non-Linnaean class of bacteria described by physiology
59343002 | Anaerobic bacteria (organism) | (http://snomed.info/id/59343002)
417454003 | Non-motile Salmonella (organism) | (http://snomed.info/id/417454003)

Resistance / susceptibility qualifiers

For example, A non-Linnaean class of bacteria described by antimicrobial susceptibility
712662001 | Carbapenem resistant Enterobacteriaceae (organism) | (http://snomed.info/id/712662001)
417943000 | Methicillin susceptible Staphylococcus aureus (organism) | (http://snomed.info/id/417943000)

Modeling with resistance-type qualifiers

Organisms with resistance-type qualifiers, i.e. where the qualifiers refer to the resistance phenotype and
the organisms that are defined by the mechanism underlying the resistance phenotype, appear in the
literature and are sometimes used interchangeably. However, in creating new concepts, these terms
should be distinguished as they are separate concepts. For resistance-type qualifiers, use the
antimicrobial agent as opposed to the enzyme that the organism is producing against the said
antimicrobial agent.
For example,
Carbapenem resistant enterobacteriaceae and carbapenemase-producing enterobacteriaceae
share a significant overlap, but the former refers to the resistance phenotype, regardless of the
mechanism of resistance. The presence of gene and carbapememase production, as a resistance
mechanism, usually results in clinically relevant levels of carbapenem resistance. However, it is
possible to have only reduced susceptibility.

Validity
A number of qualifiers might be valid (e.g. aerobic microaerophilic, motile curved gram-negative bacteria). To
determine the sequence, the decision-making process is stepwise as follows:
Determined on a case-by-case basis
Highly dependent on fitting in with the model limitations (as determined by the Organism Project Group)
Based on Bergey’s Manual of Systematic Bacteriology as the primary reference

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When requesting a new qualifier, an acceptable reference must be provided. Concepts with valid qualifiers are
added to the International Release.

Organism groupings
Only authoritative taxonomic groupings are added to the SNOMED CT International Release. When requesting new
organism concepts, authoritative references must be provided. Acceptance is determined on a case-by-case basis
by authors. These concepts may evolve over time as the names evolve.

Complex or Group
The terms “complex” and “group” are often used in scientific papers. Laboratories then reflect the words
they see in those papers in their local descriptions. However, the terms used in scientific papers are not
authoritative taxonomic groupings; rather, they are just concepts used for ease of publication and
grouping sets of organisms that are similar in certain functions or structure.
Implementers must be aware these types of concepts may evolve over time. As the sophistication of
microbiology labs increases, the “members” of each complex may change and the complex concepts
actually become obsolete. For example, this has occurred for some of the Centers for Disease Control
and Prevention (CDC) groups where a number of these concepts have actually been given names and
the CDC group name is archaic.
When requesting a new group or complex, an acceptable authoritative reference must be provided. The
reference should clearly specify the list of subtypes associated with the complex/group.
Existing complex or group concepts, with grouper concepts separate from the genus, but with the same
meaning as the genus, will be inactivated in the SNOMED CT International Release.
Descriptions with group or complex as synonyms of the genus, will be deprecated from the SNOMED CT
International Release (The genus concept should be used for these concepts).

Microorganisms
Microorganism is a common grouping name for organisms, but it does not align with Linnaean
classification. Microorganisms are organisms that can only be seen using microscopy. Four major classes
could reasonably be assigned to microorganism at the highest levels. Viruses, prions, bacteria and
archaea are all microscopic. Fungi are both microscopic and macroscopic and this is also true for
animals. Finally, there are examples of organisms (e.g. Phylum Nemata) that are macroscopic as adults
but diagnostic life-cycle stages such as eggs and larvae are microscopic. Assigning and maintaining all
subtypes to this seemingly familiar organism group is problematic and would be time and resource
intensive. This concept has been deprecated and will not be added to the organism hierarchy.

Biotype, Serotype, Serogroup

Requests for new concepts are evaluated on a case-by-case basis.
It is important to understand the meaning from the requestor and determine how it can be modeled.
These concepts may evolve over time as the names evolve.

Multidrug-resistant, extensively drug-resistant, pan drug-resistant bacteria

DRAFT UNDER REVIEW: CONTENT TO BE FINALIZED

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SNOMED International adopted the recommendations of a joint initiative of the European Centre for Disease
Prevention and Control (ECDC) and the CDC for the characterization of the different patterns of resistance found in
healthcare-associated, antimicrobial resistant bacteria. A panel of international experts convened and drafted a
proposal which provides clear consensus definitions. Please refer to the following article for details: Magiorakos, A.
Srinivasan, A. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert
proposal for interim standard definitions for acquired resistance. Clinical Microbiol Infect 2012; 18: 268-281.

Organism Naming Conventions

Fully Specified Name

The fully specified name (FSN) of organism concepts names classes that are officially recognized Linnaean
taxonomic classes (other than species), and include a designation of rank. They include, but are not limited to
Phylum, Order, Suborder, Class, Family, Genus, and subspecies.
Properly constructed FSN descriptions contain single word terms indicating the taxonomic rank + the recognized
name of that rank + hierarchy designator.
For example,
106544002 | Family Enterobacteriaceae (organism) | (http://snomed.info/id/106544002)

Rank
The naming convention is not applied to concepts that only refer to a subgroup of a rank.
For example,
113727004 | Vancomycin resistant enterococcus (organism) | (http://snomed.info/id/113727004) is
correct. It refers to a subclass of the genus, Enterococcus species that are resistant.
Incorrect example,
Vancomycin resistant Genus Enterococcus is incorrect. It refers to the rank only, Genus
Enterococcus.

Official names of organisms may include abbreviations such as “subg.“ (Kingdom Plantae) and “subsp.” and “subgen.”
(Domain Bacteria). Official names of organisms may also include parentheses e.g. “Cypraea (Cypraea) tigris”
(Kingdom Animalia) and “Bacillus (subgen. Bacillus Cohn 1872, 174) subtilis” (Domain Bacteria).
The FSN of organisms should include the expanded word for rank i.e. “subgenus” or “subspecies” and not an
abbreviation of same.
The FSN should not include parentheses.
For example
Genus Pleione subgenus Scopulorum (organism)
Genus Cypraea subgenus Cypraea tigris (organism)
Staphylococcus succinus subspecies casei (organism)

Preferred Term
The Preferred Term is the official scientific name. They may include abbreviations and/or parentheses.
For example,
Cypraea (Cypraea) tigris
Pleione subg. Scopulorum
Bacillus (subgen. Bacillus Cohn 1872, 174) subtilis
Staphylococcus succinus subsp. casei

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Qualifiers in organism names

When modeling organisms with qualifiers, the qualifier should be placed in front of the organism name.

Organism class variants

The description of organism classes that are subspecies subtypes and variants may include terms such as
serogroup, serotype, biotype, variant, biovar, serovar, and pathovar.
For example,
698206009 | Brucella suis biovar 4 (organism) | (http://snomed.info/id/698206009)
The subspecies types and variants should be included in the FSN, PT and other descriptions. This is to avoid
ambiguity when the same number or letter is used to refer to different organism variants.
For example, without mentioning the specific variant (serogroup vs. serotype) and the nomenclature system (Danish
vs. American), "Streptococcus pneumoniae 48" can refer to the following:
Streptococcus pneumoniae Danish serotype 48 (which is equvalent to Streptococcus pneumoniae American
serotype 82)
Streptococcus pneumoniae American serotype 48 (which is equivalent to Streptococcus pneumoniae Danish
serotype 7B)
Streptococcus pneumoniae serogroup 48
Abbreviations (var, var., sv, sv., bv, bv., pv, pv.) must not be used in the FSN.

Capitalization of organism names and binomial format

Official scientific names for organisms should be capitalized. The designation of rank does not require capitalization.
For example,
426813007 | Order Acidobacteriales (organism) | (http://snomed.info/id/426813007) has case significance of
“Initial character case insensitive”
There is an exception to the above guidelines where the binomial format for an organism species includes
capitalization of the genus name but the species name begins with a lower-case letter.
For example,
24224000 | Brucella abortus (organism) | (http://snomed.info/id/24224000)

Salmonella serotype nomenclature

Salmonella serotypes have a quadrinomial format of Genus species subspecies Serotype where the serotype name
is capitalized.
For example,
A synonym for 114683003 | Salmonella Doel (organism) | (http://snomed.info/id/114683003) is Salmonella
enterica subsp. enterica ser. Doel
Additional descriptions, without the species and subspecies names, are in common usage for Salmonella serotypes.
For example,
656008 | Salmonella Os (organism) | (http://snomed.info/id/656008)
In SNOMED CT, the serotype name in the description should be capitalized.

Salmonella Serotypes
Salmonella serotypes, without the species and subspecies names, should not be confused with binomial
species names of other organisms.

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Streptococcus pneumoniae
S treptococcus pneumoniae is a human pathogen whose virulence is based on its protective polysaccharide
capsule. Study of the polysaccharide capsule has identified multiple serogroups and serotypes. Serotypes are
defined by the chemical structure and immunologic properties of their polysaccharide; each serogroup contains
one or more serotypes that elicit the same antibody response.
There are two serotype naming systems, one in the U.S. and one in Denmark. The Danish system is nearly
universally accepted and preferred. For details, please refer to See Geno K A, Gilbert G L, Song J Y, Skovsted I C,
Klugman K P, Jones C, Konradsen H B, Nahm M H. Pneumococcal capsules and their types: past, present, and future.
Clinical Microbiology Reviews 2015; 28(3):871-899. [PMID: 26085553 (https://www.ncbi.nlm.nih.gov/pubmed/26085553)]).

Streptococcus pneumoniae concepts

A review of Streptococcus pneumoniae serotypes in SNOMED CT showed lack of specificity, as well as
inconsistency, in the naming of Streptococcus pneumoniae serotypes. Guidelines for creating concepts containing
Streptococcus pneumoniae serotypes were formulated. They are as follows:
FSN and preferred term (PT) descriptions should follow the Danish naming system. When an American synonym
exists, it should be added. A synonym (SYN) that matches the FSN, but does not contain the naming system can also
be added.
For example,
698149000 | Streptococcus pneumoniae serotype 48 (organism) | (http://snomed.info/id/698149000) is renamed as
follows:
FSN: Streptococcus pneumoniae Danish serotype 48 (organism)
PT: Streptococcus pneumoniae Danish serotype 48
SYN: Streptococcus pneumoniae American serotype 82
SYN: Streptococcus pneumoniae serotype 48
The guidelines for creating new concepts containing Streptococcus pneumoniae serotypes also apply to concepts
in other SNOMED CT hierarchies, such substances and procedures.
For example,
120683007 | Streptococcus pneumoniae serotype 7F antibody (substance) | (http://snomed.info/id/120683007) is
renamed as follows:
FSN: Antibody to Streptococcus pneumoniae Danish serotype 7F (substance)
PT: Streptococcus pneumoniae Danish serotype 7F Ab
SYN: Antibody to Streptococcus pneumoniae Danish serotype 7F
SYN: Anti-Streptococcus pneumoniae Danish serotype 7F antibody
SYN: Streptococcus pneumoniae Danish serotype 7F antibody
SYN: Antibody to Streptococcus pneumoniae American serotype 51

Legacy Streptococcus pneumoniae concepts

FSNs that adhered to one of the naming systems were kept, but changes were made to the descriptions, based on
the above guidelines. Any resulting duplicates were deprecated.
FSNs that did not adhere to one of the naming system were inactivated as ambiguous. They were replaced with
newly created concepts, based on the above guidelines.
Missing serotype concepts were added.

Influenza virus nomenclature

Follow the latest names for genus and species according to the taxonomy authority. Although the genus and
species names for influenza viruses are similar, they each follow a distinct pattern, which should be used in
SNOMED CT . Also, the name of the virus should always be capitalized.

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For species, the word virus is included as a separate word and follows the letter designation.
For example,
407482004 | Influenza C virus (organism) | (http://snomed.info/id/407482004)
710661004 | Immunoglobulin M antibody to Influenza B virus (substance) | (http://snomed.info/id/710661004)
10674911000119108 | Otitis media caused by Influenza A virus (disorder) | (http://snomed.info/id
/10674911000119108)

For genus, virus is included in the genus name and is not a separate word.
For example,
407481006 | Genus Gammainfluenzavirus (organism) | (http://snomed.info/id/407481006)
407477006 | Genus Alphainfluenzavirus (organism) | (http://snomed.info/id/407477006)
The disorder influenza need not be capitalized.
For example,
16311000119108 | Pneumonia caused by influenza (disorder) | (http://snomed.info/id/16311000119108)
309789002 | Encephalitis caused by influenza (disorder) | (http://snomed.info/id/309789002)

US/GB spelling variants for taxonomic concepts

Taxonomic resources (e.g. Integrated Taxonomic Information System or ITIS, List of Prokaryotic names with
Standing in Nomenclature or LPSN) use the official scientific name for organisms. Similarly, in SNOMED CT, the
official scientific name should be used in FSNs and PTs. For descriptions representing common names, if the spelling
in a country or region is different, the preferred spelling should be added in the language RefSet extension as a
synonym.

Use of X species
In the context of the Linnaean organism hierarchy, there is no difference between Salmonella species and simply
Salmonella, the genus. Terms with X species, such as Salmonella species, are routinely used in laboratory reporting.
They may provide additional information, other than the place of the organism in the Linnaean hierarchy. However,
the intended connotation may vary from lab to lab and from organism to organism.
Since the organism concept represents a class of organisms, it cannot also represent what was, was not, or what
will be done to identify the organism. Neither can it represent other information about the result. If there is
additional information to report, it should be in a separate statement or comment (e.g. further species identification
pending or sent to reference laboratory for further identification or further identification to be done if clinically
indicated).

X species
Addition of X species as a description to X genus is allowed and is done per request.

Microorganism name changes

Microorganism taxonomic names may change, often due to scientific advances. This may result in:
Finding an organism in a particular taxonomic group (e.g. Genus) that is unrelated, on a molecular basis, to
other members of the group.
Reassessing the taxonomic group originally established, based on phenotypic characteristics.
Proposing to reassign the organism to a different existing or new taxonomic group.
On a case by case basis, requests for name changes are based on the following use cases :
The name of an organism changes.
Change the FSN for affected concepts, but not the concept ID by creating a new FSN and description
Retain the old name as a synonym.

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A single species is reclassified as multiple species.

Create the new concepts.
Inactivate the original concept as ambiguous.
Set a possibly equivalent to relationship between the old concept and the new concepts.
Multiple species are reclassified as one.
Create a new concept.
Inactivate the existing concepts as outdated with replaced by relationships to the new concept.

Organism life stages

Concepts in the organism hierarchy represent fully realized organisms. An organism's life cycle stage is a
characteristic of a given taxon. It represents different stages of life e.g. egg, larva, and adult.
Organism stages themselves are characteristics common to members of a given taxon.
SNOMED CT allows for the representation of an organism in a specific life cycle stage.
For example,
337915000 | Homo sapiens (organism) | (http://snomed.info/id/337915000) are organisms. Homo sapiens
include humans, in general, as well as children.
Childhood is a life cycle stage , however it is not an organism.

Similarly,
An egg of a particular nematode, e.g. 42625000 | Strongyloides stercoralis (organism) | (http://snomed.
info/id/42625000) is an organism. It is alive and can pass through other stages appropriate to its species.

However, the egg stage of Strongyloides stercoralis is not an organism. Many diagnostic test results,
identify organisms ‘participating’ in particular life cycle stages.
For example, the results of a 83033005 | Fecal analysis (procedure) | (http://snomed.info/id/83033005) may identify the
presence of 609326000 | Larva of Strongyloides stercoralis (organism) | (http://snomed.info/id/609326000) and
699572004 | Egg of Strongyloides stercoralis (organism) | (http://snomed.info/id/699572004).

Organism concepts
Concepts in the organism hierarchy should not represent organism structures (e.g. fungal hyphae). In
addition, the word " stage" should be excluded from concepts representing life cycle of an organism (e.g.
larval stage of a nematode parasite). This does not preclude representations of organisms ‘participating’
in a specific stage of life e.g. 609061000 |Larva of genus Ascaris (organism)|.

Naming patterns
FSN pattern: (Life cycle stage) of (Taxon including rank, if required) (organism)
For example,
609043009 | Adult of phylum Nemata (organism) | (http://snomed.info/id/609043009)
699572004 | Egg of Strongyloides stercoralis (organism) | (http://snomed.info/id/699572004)
The name of the rank is included with the first letter lower case, except at the species and subspecies levels, where
the Linnaean binomial and trinomial are specified.
PT pattern: (Taxon including rank, if required) (life cycle stage)
For example,
Phylum Nemata adult
Strongyloides stercoralis egg

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Cestode larvae
A number of cestode larvae have historically been referred to using Linnaean binomial names that are completely
different from corresponding adult (or egg) names.
For example,
47399003 | Larva of Taenia saginata (organism) | (http://snomed.info/id/47399003), a human tapeworm, is usually
called Cysticercus bovis.
PT pattern: Linnaean binomial of larva OR (Taxon including rank if required) (life cycle stage)
For example,
Cysticercus bovis
Cysticercus cellulosae
Class Cestoda larva
Although rare, a subtype of cestode larva may appear to be a Linnaean trinomial name. This, then, is the PT:
Diphyllobothrium latum sparganum

Other acceptable synonyms

Some organisms and stages are referred to in an adjectival form (e.g. Ascarid egg) or by common name (e.g. adult
nematode). When used (especially when described as part of a request), these terms may be included as additional
synonyms.

Resources for organism naming

SNOMED International utilizes various resources when reviewing changes to the organism hierarchy. They include:

Bacteria
List of Prokaryotic names with Standing in Nomenclature (LPSN)
International Committee on Systematics of Prokaryotes (ICSP)
International Journal of Systematic and Evolutionary Microbiology
DSMZ-Prokaryotic Nomenclature Up-to-date

Fungi
MycoBank Database
Index Fungorum

Viruses
International Committee on Taxonomy of Viruses (ICTV)

Parasites
National Center for Biotechnology Information (NCBI) Taxonomy (Although not an authoritative source,
provides useful links to other sources; used by Unified Medical Language System (UMLS) as a QA source)

General
Integrated Taxonomic Information System (ITIS) (Covers a limited number of organisms)

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Pharmaceutical/Biologic Product
The Pharmaceutical / biologic product hierarchy is comprised of multiple smaller hierarchies, e.g. the Medicinal
product hierarchy.
Editorial guidelines for the Pharmaceutical / biologic product hierarchy are available on the Drugs Project page here:
Drugs Project.
There are frequent iterations of the editorial guidelines for the Pharmaceutical / biologic product hierarchy with the
opportunity for review and comment. Announcements, that include links to the current iteration and deadlines for
submission of comments, can be found on the project Confluence site.

Definition

A top-level hierarchy to clearly distinguish drug products (products) from their chemical constituents (substances)

Pharmaceutical/Biologic Product Attributes Summary

Editorial guidelines for the 373873005 | Pharmaceutical / biologic product (product) | (http://snomed.info/id/373873005)
hierarchy are available on the Drugs Project page here: Drugs Project .
When authoring in this domain, these are the approved attributes and allowable ranges. They are the Human
Readable Concept Model (HRCM). HRCM 2020-01-31

Domain Information for 373873005 | Pharmaceutical / biologic product (product) | (http://snomed.info/id/373873005)

Domain Constraint << 373873005 | Pharmaceutical / biologic product (product) | (http://snomed.info/id

/373873005)

Parent Domain -

Proximal Primitive << 373873005 | Pharmaceutical / biologic product (product) | (http://snomed.info/id

Constraint /373873005)

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 373873005 | Pharmaceutical / biologic product (product) | (http://snomed.
info/id/373873005)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

766953001 | Count of active 0 0..1 0..0 < 260299005 | Number (qualifier

ingredient (attribute) | ( value) | (http://snomed.info/id/260299005
http://snomed.info/id/766953001) )

766954007 | Count of base and 0 0..1 0..0 < 260299005 | Number (qualifier
modification pair (attribute) | ( value) | (http://snomed.info/id/260299005
http://snomed.info/id/766954007) )

0 0..1 0..0

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766952006 | Count of base of < 260299005 | Number (qualifier

active ingredient (attribute) | ( value) | (http://snomed.info/id/260299005
http://snomed.info/id/766952006) )

732943007 | Has basis of 1 0..* 0..1 < 105590001 | Substance (substance)

strength substance (attribute) | ( | (http://snomed.info/id/105590001)
http://snomed.info/id/732943007)

127489000 | Has active 1 0..* 0..1 << 105590001 | Substance

ingredient (attribute) | ( (substance) | (http://snomed.info/id
http://snomed.info/id/127489000) /105590001)

733722007 | Has concentration 1 0..* 0..1 < 767524001 | Unit of measure

strength denominator unit (qualifier value) | (http://snomed.info/id
(attribute) | (http://snomed.info/id /767524001)
/733722007)

733723002 | Has concentration 1 0..* 0..1 < 260299005 | Number (qualifier

strength denominator value value) | (http://snomed.info/id/260299005
(attribute) | (http://snomed.info/id )
/733723002)

733725009 | Has concentration 1 0..* 0..1 < 767524001 | Unit of measure

strength numerator unit (qualifier value) | (http://snomed.info/id
(attribute) | (http://snomed.info/id /767524001)
/733725009)

733724008 | Has concentration 1 0..* 0..1 < 260299005 | Number (qualifier

strength numerator value value) | (http://snomed.info/id/260299005
(attribute) | (http://snomed.info/id )
/733724008)

762951001 | Has ingredient -

(attribute) | (http://snomed.info/id
/762951001)

411116001 | Has manufactured 0 0..1 0..0 << 736542009 | Pharmaceutical dose

dose form (attribute) | ( form (dose form) | (http://snomed.info/id
http://snomed.info/id/411116001) /736542009)

762949000 | Has precise active 1 0..* 0..1 << 105590001 | Substance

ingredient (attribute) | ( (substance) | (http://snomed.info/id
http://snomed.info/id/762949000) /105590001)

732947008 | Has presentation 1 0..* 0..1 < 767524001 | Unit of measure

strength denominator unit (qualifier value) | (http://snomed.info/id
(attribute) | (http://snomed.info/id /767524001)
/732947008)

732946004 | Has presentation 1 0..* 0..1 < 260299005 | Number (qualifier

strength denominator value value) | (http://snomed.info/id/260299005
(attribute) | (http://snomed.info/id )
/732946004)

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 SNOMED CT Editorial Guide

732945000 | Has presentation 1 0..* 0..1 < 767524001 | Unit of measure

strength numerator unit (qualifier value) | (http://snomed.info/id
(attribute) | (http://snomed.info/id /767524001)
/732945000)

732944001 | Has presentation 1 0..* 0..1 < 260299005 | Number (qualifier

strength numerator value value) | (http://snomed.info/id/260299005
(attribute) | (http://snomed.info/id )
/732944001)

774158006 | Has product name 0 0..1 0..0 << 774167006 | Product name
(attribute) | (http://snomed.info/id (product name) | (http://snomed.info/id
/774158006) /774167006)

774159003 | Has supplier 0 0..1 0..0 << 774164004 | Supplier (supplier) | (

(attribute) | (http://snomed.info/id http://snomed.info/id/774164004)
/774159003)

763032000 | Has unit of 0 0..1 0..0 << 732935002 | Unit of presentation

presentation (attribute) | ( (unit of presentation) | (http://snomed.
http://snomed.info/id/763032000) info/id/732935002)

766939001 | Plays role 0 0..* 0..0 << 766940004 | Role (role) | (

(attribute) | (http://snomed.info/id http://snomed.info/id/766940004)
/766939001)

HRCM 2020-01-31

Domain Information for 781405001 | Medicinal product package (product) | (http://snomed.info/id/781405001)

Domain Constraint << 781405001 | Medicinal product package (product) | (http://snomed.info/id/781405001)

Parent Domain 373873005 | Pharmaceutical / biologic product (product) | (http://snomed.info/id

/373873005)

Proximal Primitive << 781405001 | Medicinal product package (product) | (http://snomed.info/id/781405001)

Constraint

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 781405001 | Medicinal product package (product) | (http://snomed.info/id
/781405001)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

774160008 | Contains clinical 1 1..* 1..1 << 763158003 | Medicinal product

drug (attribute) | (http://snomed. (product) | (http://snomed.info/id
info/id/774160008) /763158003)

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 SNOMED CT Editorial Guide

766953001 | Count of active 0 0..1 0..0 < 260299005 | Number (qualifier

ingredient (attribute) | ( value) | (http://snomed.info/id/260299005
http://snomed.info/id/766953001) )

766954007 | Count of base and 0 0..1 0..0 < 260299005 | Number (qualifier
modification pair (attribute) | ( value) | (http://snomed.info/id/260299005
http://snomed.info/id/766954007) )

766952006 | Count of base of 0 0..1 0..0 < 260299005 | Number (qualifier

active ingredient (attribute) | ( value) | (http://snomed.info/id/260299005
http://snomed.info/id/766952006) )

784276002 | Count of clinical 0 1..1 0..0 < 260299005 | Number (qualifier

drug type (attribute) | ( value) | (http://snomed.info/id/260299005
http://snomed.info/id/784276002) )

732943007 | Has basis of 1 0..* 0..1 < 105590001 | Substance (substance)

strength substance (attribute) | ( | (http://snomed.info/id/105590001)
http://snomed.info/id/732943007)

127489000 | Has active 1 0..* 0..1 << 105590001 | Substance

ingredient (attribute) | ( (substance) | (http://snomed.info/id
http://snomed.info/id/127489000) /105590001)

733722007 | Has concentration 1 0..* 0..1 < 767524001 | Unit of measure

strength denominator unit (qualifier value) | (http://snomed.info/id
(attribute) | (http://snomed.info/id /767524001)
/733722007)

733723002 | Has concentration 1 0..* 0..1 < 260299005 | Number (qualifier

strength denominator value value) | (http://snomed.info/id/260299005
(attribute) | (http://snomed.info/id )
/733723002)

733725009 | Has concentration 1 0..* 0..1 < 767524001 | Unit of measure

strength numerator unit (qualifier value) | (http://snomed.info/id
(attribute) | (http://snomed.info/id /767524001)
/733725009)

733724008 | Has concentration 1 0..* 0..1 < 260299005 | Number (qualifier

strength numerator value value) | (http://snomed.info/id/260299005
(attribute) | (http://snomed.info/id )
/733724008)

762951001 | Has ingredient -

(attribute) | (http://snomed.info/id
/762951001)

411116001 | Has manufactured 0 0..1 0..0 << 736542009 | Pharmaceutical dose

dose form (attribute) | ( form (dose form) | (http://snomed.info/id
http://snomed.info/id/411116001) /736542009)

1 0..* 0..1

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 SNOMED CT Editorial Guide

774161007 | Has pack size < 260299005 | Number (qualifier

(attribute) | (http://snomed.info/id value) | (http://snomed.info/id/260299005
/774161007) )

774163005 | Has pack size unit 1 0..* 0..1 << 767524001 | Unit of measure
(attribute) | (http://snomed.info/id (qualifier value) | (http://snomed.info/id
/774163005) /767524001)

762949000 | Has precise active 1 0..* 0..1 << 105590001 | Substance

ingredient (attribute) | ( (substance) | (http://snomed.info/id
http://snomed.info/id/762949000) /105590001)

732947008 | Has presentation 1 0..* 0..1 < 767524001 | Unit of measure

strength denominator unit (qualifier value) | (http://snomed.info/id
(attribute) | (http://snomed.info/id /767524001)
/732947008)

732946004 | Has presentation 1 0..* 0..1 < 260299005 | Number (qualifier

strength denominator value value) | (http://snomed.info/id/260299005
(attribute) | (http://snomed.info/id )
/732946004)

732945000 | Has presentation 1 0..* 0..1 < 767524001 | Unit of measure

strength numerator unit (qualifier value) | (http://snomed.info/id
(attribute) | (http://snomed.info/id /767524001)
/732945000)

732944001 | Has presentation 1 0..* 0..1 < 260299005 | Number (qualifier

strength numerator value value) | (http://snomed.info/id/260299005
(attribute) | (http://snomed.info/id )
/732944001)

774158006 | Has product name 0 0..1 0..0 << 774167006 | Product name
(attribute) | (http://snomed.info/id (product name) | (http://snomed.info/id
/774158006) /774167006)

774159003 | Has supplier 0 0..1 0..0 << 774164004 | Supplier (supplier) | (

(attribute) | (http://snomed.info/id http://snomed.info/id/774164004)
/774159003)

763032000 | Has unit of 0 0..1 0..0 << 732935002 | Unit of presentation

presentation (attribute) | ( (unit of presentation) | (http://snomed.
http://snomed.info/id/763032000) info/id/732935002)

766939001 | Plays role 0 0..* 0..0 << 766940004 | Role (role) | (

(attribute) | (http://snomed.info/id http://snomed.info/id/766940004)
/766939001)

HRCM 2020-01-31

Domain Information for 736542009 | Pharmaceutical dose form (dose form) | (http://snomed.info/id/736542009)

Domain Constraint << 736542009 | Pharmaceutical dose form (dose form) | (http://snomed.info/id/736542009
)

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 SNOMED CT Editorial Guide

Parent Domain -

Proximal Primitive << 736542009 | Pharmaceutical dose form (dose form) | (http://snomed.info/id/736542009
Constraint )

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 736542009 | Pharmaceutical dose form (dose form) | (http://snomed.info/id
/736542009)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

736476002 | Has basic dose 0 0..1 0..0 < 736478001 | Basic dose form (basic
form (attribute) | (http://snomed. dose form) | (http://snomed.info/id
info/id/736476002) /736478001)

736472000 | Has dose form 0 0..* 0..0 < 736665006 | Dose form
administration method administration method
(attribute) | (http://snomed.info/id (administration method) | (
/736472000) http://snomed.info/id/736665006)

736474004 | Has dose form 0 0..* 0..0 < 736479009 | Dose form intended
intended site (attribute) | ( site (intended site) | (http://snomed.info
http://snomed.info/id/736474004) /id/736479009)

736475003 | Has dose form 0 0..1 0..0 < 736480007 | Dose form release
release characteristic (attribute) characteristic (release characteristic) |
| (http://snomed.info/id/736475003) (http://snomed.info/id/736480007)

736473005 | Has dose form 0 0..* 0..0 < 736477006 | Dose form
transformation (attribute) | ( transformation (transformation) | (
http://snomed.info/id/736473005) http://snomed.info/id/736477006)

HRCM 2020-01-31

Domain Information for 736478001 | Basic dose form (basic dose form) | (http://snomed.info/id/736478001)

Domain Constraint << 736478001 | Basic dose form (basic dose form) | (http://snomed.info/id/736478001)

Parent Domain -

Proximal Primitive << 736478001 | Basic dose form (basic dose form) | (http://snomed.info/id/736478001)
Constraint

Proximal Primitive -
Refinement

HRCM 2020-01-31

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 SNOMED CT Editorial Guide

Author View of Attributes and Ranges for 736478001 | Basic dose form (basic dose form) | (http://snomed.info/id
/736478001)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

736518005 | Has state of matter 0 1..1 0..0 < 736471007 | State of matter (state
(attribute) | (http://snomed.info/id of matter) | (http://snomed.info/id
/736518005) /736471007)

Physical Force*

Definition Examples

Forces applied to the body that may cause 87588000 | High altitude (physical force) | (http://snomed.info/id
injury /87588000)

263762005 | Friction (physical force) | (http://snomed.info/id

/263762005)

Physical Force
The concepts in the Physical force hierarchy primarily represent physical forces that may play a role in
injuries.

Physical Object

Definition Examples

Physical devices relevant to health care, or to injuries 469785004 | Heel protector (physical object)
/accidents | (http://snomed.info/id/469785004)
40388003 | Implant, device (physical object)
| (http://snomed.info/id/40388003)

Editorial guidelines for the Physical object hierarchy are available on the Devices Project page here: Devices Project.
There are frequent iterations of the editorial guidelines for the Physical object hierarchy with the opportunity for
review and comment. Announcements and project plans can be found on the project Confluence site.

Physical Object
Concepts in the Physical object hierarchy include natural and man-made objects. One use for these
concepts is modeling procedures that use devices (e.g. catheterization).

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 SNOMED CT Editorial Guide

Procedure

Definition Examples

Procedure: activities performed in the provision of 54321008 | Cardiac flow imaging (procedure) | (
health care (includes medical history-taking, http://snomed.info/id/54321008)
physical examination, diagnostic and therapeutic
386513007 | Anesthesia management (regime
interventions, training and education, and
/therapy) | (http://snomed.info/id/386513007)
counseling)
Regime/therapy (subtype of procedure): set of
procedures focused on a single purpose on one
patient over time (e.g. repeated administration of
drug in a small dose for an indefinite period of
time)

Procedure concepts
Procedure concepts represent activities performed in the provision of health care. This hierarchy represents a broad
variety of activities, including but not limited to:
Invasive procedures, e.g. 77018005 | Excision of lesion of intracranial artery (procedure) | (http://snomed.info/id
/77018005)

Administration of medicines, e.g. 39343008 | Pertussis vaccination (procedure) | (http://snomed.info/id/39343008)

Imaging procedures, e.g. 47079000 | Ultrasonography of breast (procedure) | (http://snomed.info/id/47079000)
Education procedures, e.g. 183063000 | Low salt diet education (procedure) | (http://snomed.info/id/183063000)
Administrative procedures, e.g. 305212007 | Medical records transfer (procedure) | (http://snomed.info/id
/305212007)

Procedure Attributes Summary

When authoring in this domain, these are the approved attributes and allowable ranges. They are from the Human
Readable Concept Model (HRCM). In addition, 386053000 | Evaluation procedure (procedure) | (http://snomed.info/id
/386053000), 387713003 | Surgical procedure (procedure) | (http://snomed.info/id/387713003), and 433590000 |
Administration of substance via specific route (procedure) | (http://snomed.info/id/433590000) each have unique
defining attributes as seen in their separate tables below. HRCM 2020-01-31

Domain Information for 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002)

Domain Constraint << 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002)

Parent Domain -

Proximal Primitive << 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002)

Constraint

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002)

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 SNOMED CT Editorial Guide

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

260507000 | Access (attribute) 1 0..* 0..1 << 309795001 | Surgical access values
| (http://snomed.info/id/260507000 (qualifier value) | (http://snomed.info/id
) /309795001)

363699004 | Direct device 1 0..* 0..1 << 49062001 | Device (physical object)
(attribute) | (http://snomed.info/id | (http://snomed.info/id/49062001)
/363699004)

363700003 | Direct 1 0..* 0..1 << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/363700003) abnormality) | (http://snomed.info/id
/49755003)

363701004 | Direct substance 1 0..* 0..1 << 105590001 | Substance (substance)

(attribute) | (http://snomed.info/id | (http://snomed.info/id/105590001) OR
/363701004) << 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005)

363702006 | Has focus 1 0..* 0..1 << 404684003 | Clinical finding

(attribute) | (http://snomed.info/id (finding) | (http://snomed.info/id
/363702006) /404684003) OR
<< 71388002 | Procedure (procedure) |
(http://snomed.info/id/71388002)

363703001 | Has intent 1 0..* 0..1 << 363675004 | Intents (nature of

(attribute) | (http://snomed.info/id procedure values) (qualifier value) | (
/363703001) http://snomed.info/id/363675004)

363710007 | Indirect device 1 0..* 0..1 << 49062001 | Device (physical object)
(attribute) | (http://snomed.info/id | (http://snomed.info/id/49062001)
/363710007)

363709002 | Indirect 1 0..* 0..1 << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/363709002) abnormality) | (http://snomed.info/id
/49755003)

260686004 | Method (attribute) 1 0..* 0..1 << 129264002 | Action (qualifier value)
| (http://snomed.info/id/260686004) | (http://snomed.info/id/129264002)

260870009 | Priority (attribute) 1 0..* 0..1 << 272125009 | Priorities (qualifier

| (http://snomed.info/id/260870009) value) | (http://snomed.info/id/272125009)

405815000 | Procedure device 1 0..* 0..* << 49062001 | Device (physical object)
(attribute) | (http://snomed.info/id | (http://snomed.info/id/49062001)
/405815000)

405816004 | Procedure 1 0..* 0..*

morphology (attribute) | (
http://snomed.info/id/405816004)

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 SNOMED CT Editorial Guide

<< 49755003 | Morphologically

abnormal structure (morphologic
abnormality) | (http://snomed.info/id
/49755003)

363704007 | Procedure site 1 0..* 0..* << 442083009 | Anatomical or

(attribute) | (http://snomed.info/id acquired body structure (body
/363704007) structure) | (http://snomed.info/id
/442083009)

405813007 | Procedure site - 1 0..* 0..1 << 442083009 | Anatomical or

Direct (attribute) | (http://snomed. acquired body structure (body
info/id/405813007) structure) | (http://snomed.info/id
/442083009)

405814001 | Procedure site - 1 0..* 0..1 << 442083009 | Anatomical or

Indirect (attribute) | ( acquired body structure (body
http://snomed.info/id/405814001) structure) | (http://snomed.info/id
/442083009)

370131001 | Recipient category 1 0..* 0..1 << 125676002 | Person (person) | (

(attribute) | (http://snomed.info/id http://snomed.info/id/125676002) OR
/370131001) << 35359004 | Family (social concept)
| (http://snomed.info/id/35359004) OR
<< 133928008 | Community (social
concept) | (http://snomed.info/id
/133928008) OR
<< 389109008 | Group (social concept)
| (http://snomed.info/id/389109008)

246513007 | Revision status 1 0..* 0..1 << 261424001 | Primary operation

(attribute) | (http://snomed.info/id (qualifier value) | (http://snomed.info/id
/246513007) /261424001) OR
<< 255231005 | Revision - value
(qualifier value) | (http://snomed.info/id
/255231005) OR
<< 257958009 | Part of multistage
procedure (qualifier value) | (
http://snomed.info/id/257958009)

425391005 | Using access 1 0..* 0..1 << 49062001 | Device (physical object)
device (attribute) | ( | (http://snomed.info/id/49062001)
http://snomed.info/id/425391005)

424226004 | Using device 1 0..* 0..* << 49062001 | Device (physical object)
(attribute) | (http://snomed.info/id | (http://snomed.info/id/49062001)
/424226004)

424244007 | Using energy 1 0..* 0..1 << 78621006 | Physical force (physical
(attribute) | (http://snomed.info/id force) | (http://snomed.info/id/78621006)
/424244007)

424361007 | Using substance 1 0..* 0..1 << 105590001 | Substance (substance)

(attribute) | (http://snomed.info/id | (http://snomed.info/id/105590001)
/424361007)

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HRCM 2020-01-31

Domain Information for 386053000 | Evaluation procedure (procedure) | (http://snomed.info/id/386053000)

Domain Constraint << 386053000 | Evaluation procedure (procedure) | (http://snomed.info/id/386053000)

Parent Domain 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002)

Proximal Primitive << 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002)

Constraint

Proximal Primitive [[1..*]] 260686004 | Method | (http://snomed.info/id/260686004) = [[+id(<< 129265001 |

Refinement Evaluation - action | (http://snomed.info/id/129265001) )]]

HRCM 2020-01-31

Author View of Attributes and Ranges for 386053000 | Evaluation procedure (procedure) | (http://snomed.info/id
/386053000)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

260507000 | Access (attribute) | 1 0..* 0..1 << 309795001 | Surgical access values
(http://snomed.info/id/260507000) (qualifier value) | (http://snomed.info/id
/309795001)

246093002 | Component 1 0..* 0..1 << 123037004 | Body structure (body

(attribute) | (http://snomed.info/id structure) | (http://snomed.info/id
/246093002) /123037004) OR
<< 410607006 | Organism (organism)
| (http://snomed.info/id/410607006) OR
<< 105590001 | Substance (substance)
| (http://snomed.info/id/105590001) OR
<< 123038009 | Specimen (specimen)
| (http://snomed.info/id/123038009) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004) OR
<< 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005) OR
<< 419891008 | Record artifact (record
artifact) | (http://snomed.info/id
/419891008)

363699004 | Direct device 1 0..* 0..1 << 49062001 | Device (physical

(attribute) | (http://snomed.info/id object) | (http://snomed.info/id/49062001)
/363699004)

363700003 | Direct morphology 1 0..* 0..1 << 49755003 | Morphologically

(attribute) | (http://snomed.info/id abnormal structure (morphologic
/363700003) abnormality) | (http://snomed.info/id
/49755003)

1 0..* 0..1

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 SNOMED CT Editorial Guide

363701004 | Direct substance << 105590001 | Substance (substance)

(attribute) | (http://snomed.info/id | (http://snomed.info/id/105590001) OR
/363701004) << 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005)

363702006 | Has focus 1 0..* 0..1 << 404684003 | Clinical finding

(attribute) | (http://snomed.info/id (finding) | (http://snomed.info/id
/363702006) /404684003) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002)

363703001 | Has intent 1 0..* 0..1 << 363675004 | Intents (nature of

(attribute) | (http://snomed.info/id procedure values) (qualifier value) | (
/363703001) http://snomed.info/id/363675004)

116686009 | Has specimen 1 0..* 0..1 << 123038009 | Specimen (specimen)

(attribute) | (http://snomed.info/id | (http://snomed.info/id/123038009)
/116686009)

363710007 | Indirect device 1 0..* 0..1 << 49062001 | Device (physical

(attribute) | (http://snomed.info/id object) | (http://snomed.info/id/49062001)
/363710007)

363709002 | Indirect 1 0..* 0..1 << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/363709002) abnormality) | (http://snomed.info/id
/49755003)

370129005 | Measurement 1 0..* 0..1 << 127789004 | Laboratory procedure

method (attribute) | ( categorized by method (procedure) | (
http://snomed.info/id/370129005) http://snomed.info/id/127789004)

260686004 | Method (attribute) 1 0..* 0..1 << 129264002 | Action (qualifier

| (http://snomed.info/id/260686004) value) | (http://snomed.info/id/129264002)

260870009 | Priority (attribute) | 1 0..* 0..1 << 272125009 | Priorities (qualifier

(http://snomed.info/id/260870009) value) | (http://snomed.info/id/272125009)

405815000 | Procedure device 1 0..* 0..* << 49062001 | Device (physical

(attribute) | (http://snomed.info/id object) | (http://snomed.info/id/49062001)
/405815000)

405816004 | Procedure 1 0..* 0..* << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/405816004) abnormality) | (http://snomed.info/id
/49755003)

363704007 | Procedure site 1 0..* 0..* << 442083009 | Anatomical or

(attribute) | (http://snomed.info/id acquired body structure (body
/363704007) structure) | (http://snomed.info/id
/442083009)

1 0..* 0..1

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405813007 | Procedure site - << 442083009 | Anatomical or

Direct (attribute) | (http://snomed. acquired body structure (body
info/id/405813007) structure) | (http://snomed.info/id
/442083009)

405814001 | Procedure site - 1 0..* 0..1 << 442083009 | Anatomical or

Indirect (attribute) | ( acquired body structure (body
http://snomed.info/id/405814001) structure) | (http://snomed.info/id
/442083009)

370130000 | Property (attribute) 1 0..1 0..1 << 118598001 | Property of

| (http://snomed.info/id/370130000) measurement (qualifier value) | (
http://snomed.info/id/118598001)

370131001 | Recipient category 1 0..* 0..1 << 125676002 | Person (person) | (

(attribute) | (http://snomed.info/id http://snomed.info/id/125676002) OR
/370131001) << 35359004 | Family (social concept)
| (http://snomed.info/id/35359004) OR
<< 133928008 | Community (social
concept) | (http://snomed.info/id
/133928008) OR
<< 389109008 | Group (social
concept) | (http://snomed.info/id
/389109008)

246513007 | Revision status 1 0..* 0..1 << 261424001 | Primary operation

(attribute) | (http://snomed.info/id (qualifier value) | (http://snomed.info/id
/246513007) /261424001) OR
<< 255231005 | Revision - value
(qualifier value) | (http://snomed.info/id
/255231005) OR
<< 257958009 | Part of multistage
procedure (qualifier value) | (
http://snomed.info/id/257958009)

370132008 | Scale type 1 0..1 0..1 << 30766002 | Quantitative | (

(attribute) | (http://snomed.info/id http://snomed.info/id/30766002) OR
/370132008) << 26716007 | Qualitative | (
http://snomed.info/id/26716007) OR
<< 117363000 | Ordinal value | (
http://snomed.info/id/117363000) OR
<< 117365007 | Ordinal or quantitative
value | (http://snomed.info/id/117365007)
OR
<< 117362005 | Nominal value | (
http://snomed.info/id/117362005) OR
<< 117364006 | Narrative value | (
http://snomed.info/id/117364006) OR
<< 117444000 | Text value | (
http://snomed.info/id/117444000)

370134009 | Time aspect 1 0..1 0..1 << 7389001 | Time frame (qualifier
(attribute) | (http://snomed.info/id value) | (http://snomed.info/id/7389001)
/370134009)

1 0..* 0..1 << 49062001 | Device (physical

object) | (http://snomed.info/id/49062001)

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425391005 | Using access

device (attribute) | (http://snomed.
info/id/425391005)

424226004 | Using device 1 0..* 0..* << 49062001 | Device (physical

(attribute) | (http://snomed.info/id object) | (http://snomed.info/id/49062001)
/424226004)

424244007 | Using energy 1 0..* 0..1 << 78621006 | Physical force (physical
(attribute) | (http://snomed.info/id force) | (http://snomed.info/id/78621006)
/424244007)

424361007 | Using substance 1 0..* 0..1 << 105590001 | Substance (substance)

(attribute) | (http://snomed.info/id | (http://snomed.info/id/105590001)
/424361007)

HRCM 2020-01-31

Domain Information for 387713003 | Surgical procedure (procedure) | (http://snomed.info/id/387713003)

Domain Constraint << 387713003 | Surgical procedure (procedure) | (http://snomed.info/id/387713003)

Parent Domain 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002)

Proximal Primitive << 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002)

Constraint

Proximal Primitive [[1..*]] 260686004 | Method | (http://snomed.info/id/260686004) = [[+id(<< 129284003 |

Refinement Surgical action (qualifier value) | (http://snomed.info/id/129284003) )]]

HRCM 2020-01-31

Author View of Attributes and Ranges for 387713003 | Surgical procedure (procedure) | (http://snomed.info/id
/387713003)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

260507000 | Access (attribute) 1 0..* 0..1 << 309795001 | Surgical access values
| (http://snomed.info/id/260507000 (qualifier value) | (http://snomed.info/id
) /309795001)

363699004 | Direct device 1 0..* 0..1 << 49062001 | Device (physical object)
(attribute) | (http://snomed.info/id | (http://snomed.info/id/49062001)
/363699004)

363700003 | Direct 1 0..* 0..1 << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/363700003) abnormality) | (http://snomed.info/id
/49755003)

1 0..* 0..1

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363701004 | Direct substance << 105590001 | Substance (substance)

(attribute) | (http://snomed.info/id | (http://snomed.info/id/105590001) OR
/363701004) << 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005)

363702006 | Has focus 1 0..* 0..1 << 404684003 | Clinical finding

(attribute) | (http://snomed.info/id (finding) | (http://snomed.info/id
/363702006) /404684003) OR
<< 71388002 | Procedure (procedure) |
(http://snomed.info/id/71388002)

363703001 | Has intent 1 0..* 0..1 << 363675004 | Intents (nature of

(attribute) | (http://snomed.info/id procedure values) (qualifier value) | (
/363703001) http://snomed.info/id/363675004)

363710007 | Indirect device 1 0..* 0..1 << 49062001 | Device (physical object)
(attribute) | (http://snomed.info/id | (http://snomed.info/id/49062001)
/363710007)

363709002 | Indirect 1 0..* 0..1 << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/363709002) abnormality) | (http://snomed.info/id
/49755003)

260686004 | Method (attribute) 1 0..* 0..1 << 129264002 | Action (qualifier value)
| (http://snomed.info/id/260686004) | (http://snomed.info/id/129264002)

260870009 | Priority (attribute) 1 0..* 0..1 << 272125009 | Priorities (qualifier

| (http://snomed.info/id/260870009) value) | (http://snomed.info/id/272125009)

405815000 | Procedure device 1 0..* 0..* << 49062001 | Device (physical object)
(attribute) | (http://snomed.info/id | (http://snomed.info/id/49062001)
/405815000)

405816004 | Procedure 1 0..* 0..* << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/405816004) abnormality) | (http://snomed.info/id
/49755003)

363704007 | Procedure site 1 0..* 0..* << 442083009 | Anatomical or

(attribute) | (http://snomed.info/id acquired body structure (body
/363704007) structure) | (http://snomed.info/id
/442083009)

405813007 | Procedure site - 1 0..* 0..1 << 442083009 | Anatomical or

Direct (attribute) | (http://snomed. acquired body structure (body
info/id/405813007) structure) | (http://snomed.info/id
/442083009)

405814001 | Procedure site - 1 0..* 0..1 << 442083009 | Anatomical or

Indirect (attribute) | ( acquired body structure (body
http://snomed.info/id/405814001) structure) | (http://snomed.info/id
/442083009)

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370131001 | Recipient category 1 0..* 0..1 << 125676002 | Person (person) | (

(attribute) | (http://snomed.info/id http://snomed.info/id/125676002) OR
/370131001) << 35359004 | Family (social concept)
| (http://snomed.info/id/35359004) OR
<< 133928008 | Community (social
concept) | (http://snomed.info/id
/133928008) OR
<< 389109008 | Group (social concept)
| (http://snomed.info/id/389109008)

246513007 | Revision status 1 0..* 0..1 << 261424001 | Primary operation

(attribute) | (http://snomed.info/id (qualifier value) | (http://snomed.info/id
/246513007) /261424001) OR
<< 255231005 | Revision - value
(qualifier value) | (http://snomed.info/id
/255231005) OR
<< 257958009 | Part of multistage
procedure (qualifier value) | (
http://snomed.info/id/257958009)

424876005 | Surgical approach 1 0..* 0..1 << 103379005 | Procedural approach

(attribute) | (http://snomed.info/id (qualifier value) | (http://snomed.info/id
/424876005) /103379005)

425391005 | Using access 1 0..* 0..1 << 49062001 | Device (physical object)
device (attribute) | ( | (http://snomed.info/id/49062001)
http://snomed.info/id/425391005)

424226004 | Using device 1 0..* 0..* << 49062001 | Device (physical object)
(attribute) | (http://snomed.info/id | (http://snomed.info/id/49062001)
/424226004)

424244007 | Using energy 1 0..* 0..1 << 78621006 | Physical force (physical
(attribute) | (http://snomed.info/id force) | (http://snomed.info/id/78621006)
/424244007)

424361007 | Using substance 1 0..* 0..1 << 105590001 | Substance (substance)

(attribute) | (http://snomed.info/id | (http://snomed.info/id/105590001)
/424361007)

HRCM 2020-01-31

Domain Information for 433590000 | Administration of substance via specific route (procedure) | (http://snomed.info
/id/433590000)

Domain Constraint << 433590000 | Administration of substance via specific route (procedure) | (
http://snomed.info/id/433590000)

Parent Domain 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002)

Proximal Primitive << 71388002 | Procedure (procedure) | (http://snomed.info/id/71388002)

Constraint

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 SNOMED CT Editorial Guide

Proximal Primitive [[1..*]] 260686004 | Method | (http://snomed.info/id/260686004) = [[+id(<< 129445006 |

Refinement Administration - action (qualifier value) | (http://snomed.info/id/129445006) )]], [[1..*]]
410675002 | Route of administration (attribute) | (http://snomed.info/id/410675002) = [[+id
(<< 284009009 | Route of administration value (qualifier value) | (http://snomed.info/id
/284009009) )]], [[1..*]] 363701004 | Direct substance (attribute) | (http://snomed.info/id
/363701004) = [[+id(<< 105590001 | Substance (substance) | (http://snomed.info/id
/105590001) )]]

HRCM 2020-01-31

Author View of Attributes and Ranges for 433590000 | Administration of substance via specific route (procedure) |
(http://snomed.info/id/433590000)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

260507000 | Access (attribute) | ( 1 0..* 0..1 << 309795001 | Surgical access values
http://snomed.info/id/260507000) (qualifier value) | (http://snomed.info/id
/309795001)

363699004 | Direct device 1 0..* 0..1 << 49062001 | Device (physical

(attribute) | (http://snomed.info/id object) | (http://snomed.info/id/49062001)
/363699004)

363700003 | Direct morphology 1 0..* 0..1 << 49755003 | Morphologically

(attribute) | (http://snomed.info/id abnormal structure (morphologic
/363700003) abnormality) | (http://snomed.info/id
/49755003)

363701004 | Direct substance 1 0..* 0..1 << 105590001 | Substance

(attribute) | (http://snomed.info/id (substance) | (http://snomed.info/id
/363701004) /105590001) OR
<< 373873005 | Pharmaceutical /
biologic product (product) | (
http://snomed.info/id/373873005)

363702006 | Has focus 1 0..* 0..1 << 404684003 | Clinical finding

(attribute) | (http://snomed.info/id (finding) | (http://snomed.info/id
/363702006) /404684003) OR
<< 71388002 | Procedure (procedure)
| (http://snomed.info/id/71388002)

363703001 | Has intent 1 0..* 0..1 << 363675004 | Intents (nature of

(attribute) | (http://snomed.info/id procedure values) (qualifier value) | (
/363703001) http://snomed.info/id/363675004)

363710007 | Indirect device 1 0..* 0..1 << 49062001 | Device (physical

(attribute) | (http://snomed.info/id object) | (http://snomed.info/id/49062001)
/363710007)

363709002 | Indirect 1 0..* 0..1 << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/363709002) abnormality) | (http://snomed.info/id
/49755003)

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260686004 | Method (attribute) 1 0..* 0..1 << 129264002 | Action (qualifier

| (http://snomed.info/id/260686004) value) | (http://snomed.info/id/129264002)

260870009 | Priority (attribute) | 1 0..* 0..1 << 272125009 | Priorities (qualifier

(http://snomed.info/id/260870009) value) | (http://snomed.info/id/272125009)

405815000 | Procedure device 1 0..* 0..* << 49062001 | Device (physical

(attribute) | (http://snomed.info/id object) | (http://snomed.info/id/49062001)
/405815000)

405816004 | Procedure 1 0..* 0..* << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/405816004) abnormality) | (http://snomed.info/id
/49755003)

363704007 | Procedure site 1 0..* 0..* << 442083009 | Anatomical or

(attribute) | (http://snomed.info/id acquired body structure (body
/363704007) structure) | (http://snomed.info/id
/442083009)

405813007 | Procedure site - 1 0..* 0..1 << 442083009 | Anatomical or

Direct (attribute) | (http://snomed. acquired body structure (body
info/id/405813007) structure) | (http://snomed.info/id
/442083009)

405814001 | Procedure site - 1 0..* 0..1 << 442083009 | Anatomical or

Indirect (attribute) | ( acquired body structure (body
http://snomed.info/id/405814001) structure) | (http://snomed.info/id
/442083009)

370131001 | Recipient category 1 0..* 0..1 << 125676002 | Person (person) | (

(attribute) | (http://snomed.info/id http://snomed.info/id/125676002) OR
/370131001) << 35359004 | Family (social concept)
| (http://snomed.info/id/35359004) OR
<< 133928008 | Community (social
concept) | (http://snomed.info/id
/133928008) OR
<< 389109008 | Group (social
concept) | (http://snomed.info/id
/389109008)

246513007 | Revision status 1 0..* 0..1 << 261424001 | Primary operation

(attribute) | (http://snomed.info/id (qualifier value) | (http://snomed.info/id
/246513007) /261424001) OR
<< 255231005 | Revision - value
(qualifier value) | (http://snomed.info/id
/255231005) OR
<< 257958009 | Part of multistage
procedure (qualifier value) | (
http://snomed.info/id/257958009)

410675002 | Route of 1 0..* 0..1 << 284009009 | Route of

administration (attribute) | ( administration value (qualifier value) | (
http://snomed.info/id/410675002) http://snomed.info/id/284009009)

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425391005 | Using access 1 0..* 0..1 << 49062001 | Device (physical

device (attribute) | (http://snomed. object) | (http://snomed.info/id/49062001)
info/id/425391005)

424226004 | Using device 1 0..* 0..* << 49062001 | Device (physical

(attribute) | (http://snomed.info/id object) | (http://snomed.info/id/49062001)
/424226004)

424244007 | Using energy 1 0..* 0..1 << 78621006 | Physical force (physical
(attribute) | (http://snomed.info/id force) | (http://snomed.info/id/78621006)
/424244007)

424361007 | Using substance 1 0..* 0..1 << 105590001 | Substance

(attribute) | (http://snomed.info/id (substance) | (http://snomed.info/id
/424361007) /105590001)

Procedure Defining Attributes

The following contain the defining attributes for Procedure concepts. Evaluation, Surgical, and Administration of
Substance via Specific Route procedures each have unique defining attributes.

Procedure, General
The following defining attributes correspond to the Procedure Attributes Summary table from the HRCM.

Access
Access describes the route used to access the site of a procedure. It distinguishes open, closed, and percutaneous
procedures.
For example,
174572001 | Open removal of bile duct stent (procedure) | (http://snomed.info/id/174572001), has Open approach
- access (qualifier value)

Direct device
Direct Device represents the device on which the method directly acts.
For example,
431698006 | Adjustment of gastric banding using fluoroscopic guidance (procedure) | (http://snomed.info/id
/431698006) has Direct device, Surgical band (physical object)

Direct morphology
Direct Morphology describes the morphologically abnormal structure that is the direct object of the Method action.
For example,
31512000 | Shaving of benign lesion with chemical cauterization (procedure) | (http://snomed.info/id/31512000)
has the Direct morphology, Lesion (morphologic abnormality)

Direct substance
Direct Substance describes the Substance or Pharmaceutical/biologic product on which the procedure's method
directly acts.
For example,

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231274008 | Injection of steroid into joint (procedure) | (http://snomed.info/id/231274008) has Direct substance,
Bone cement (substance)

Pharmaceutical / biologic product

Pharmaceutical / biologic product (product) and its descendants are not used as values for Direct
Substance in the International Release.

Has focus
Has Focus specifies the Clinical finding or Procedure which is the focus of a procedure.
For example,
385941006 | Wound care assessment (procedure) | (http://snomed.info/id/385941006) Has focus, Wound care
(regime/therapy)

Has intent
Has intent is generally used only to define procedures whose FSNs explicitly specify an intent, such as 240959006 |
Therapeutic barium enema (procedure) | (http://snomed.info/id/240959006) or 274389009 | Diagnostic aspiration of
ovary (procedure) | (http://snomed.info/id/274389009). Typically it is used when a procedure may be done for either a
diagnostic or a therapeutic reason. It is not normally used to define procedures that are always inherently
diagnostic, such as biopsies, or always inherently therapeutic, such as fixation of a fracture.
For example,
108249004 | Audiologic AND/OR audiometric test including vestibular function (procedure) | (http://snomed.info
/id/108249004) has Intent, Diagnostic intent (qualifier value)

Indirect device
Indirect Device represents action on something that is located in or on a device, but is not directly on the device
itself. This attribute is infrequently needed. When modeling, carefully consider its use.
For example,
232762008 | Excision of vegetations from implanted mitral valve (procedure) | (http://snomed.info/id/232762008)
has Indirect device, Mitral valve prosthesis device (physical object).

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In this example, the vegetation is being excised. The mitral valve prosthesis device is where the vegetation is
located, but the mitral valve prosthesis, itself, is not excised. Thus, the mitral valve prosthesis device is the Indirect
device.

Indirect morphology
Indirect Morphology describes the morphology that is acted upon, but is not the direct object of the Method action.
This means the procedure acts directly on something else, e.g. a device, substance, or anatomical structure.
For example,
404205006 | Removal of mesh from wound (procedure) | (http://snomed.info/id/404205006) has Indirect
morphology, Wound (morphologic abnormality)

Method
Method represents the action being performed to accomplish the procedure. It does not include: the surgical
approach, e.g. translumbar; e quipment, e.g. sutures; or physical force, e.g. laser energy (see Surgical Procedures
Defining Attribute page).

No relationship group can contain more than one Method relationship. If a procedure has more than one
Method, each serves as the anchor of a separate relationship group that will contain any defining
relationships that represent a direct object (and, where relevant, indirect object) of the Method's action. This
is true even if the different Methods each act on the same direct object. Each relationship group can be
thought of as representing a component of the procedure that involves a particular action.

For example,
10255001 | Incision of ureter (procedure) | (http://snomed.info/id/10255001) has Method, Incision - action
(qualifier value)
Procedures with a Method attribute can be described using an action verb that corresponds to the method. The
direct object/s of the action verb should be represented using one or more of the four direct object attributes,
depending on whether the direct object on which the method acts is a:
Anatomical structure: Procedure site - Direct
Morphologic abnormality: Direct Morphology
Device: Direct Device
Substance: Direct Substance
If the body structure, device, or substance of the direct object is indeterminate, do not use the direct-object
attributes.
When modeling procedures where the Method is Removal - action (qualifier value) or one of its subtypes, e.g.
Excision, Surgical biopsy, etc. , for removal of:
Structures and Tissue lesions (e.g. cysts, tumors, etc. are considered removal of the site) use Procedure site -
Direct
Devices, calculi, thrombi, foreign bodies, and other non-tissue entities from the structure use Procedure site -
Indirect
For example,
43748006 | Removal of urinary bladder catheter (procedure) | (http://snomed.info/id/43748006) has Method,
Removal - action (qualifier value) and Procedure site - Indirect, Bladder and outflow structure (body structure)

Method attribute
Attributes should be grouped with the Method attribute to which they apply. In the absence of a Method
attribute, related attributes should be grouped together.
Exception,

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Recipient Category (see below). A single procedure concept should not be precoordinated when
more than one Recipient Category is involved. Such complex statements should have two or more
procedure concepts that are placed into an appropriately structured electronic health application.

Priority
Priority is used when a procedure concept specifies a priority.
For example,
708932005 | Emergency hemodialysis (procedure) | (http://snomed.info/id/708932005) has Priority, Emergency
(qualifier value)
177141003 | Elective cesarean section (procedure) | (http://snomed.info/id/177141003) has Priority, Elective
(qualifier value)
260870009 | Priority (attribute) | (http://snomed.info/id/260870009)is most often used to differentiate elective and
emergency subtypes of a procedure that can be performed on either basis. With the exception of Cardiopulmonary
resuscitation (procedure), this attribute is normally used only to define concepts whose FSNs specify a priority, not
for modeling procedures that imply an emergency priority, such as |Heimlich maneuver (procedure)| or those that
are inherently elective, such as |Augmentation mammoplasty (procedure)|.

Procedure device
Procedure Device is used to model devices associated with a procedure. This attribute is used to define high-level,
general concepts that aggregate procedures according to the device involved.
Procedure Device subsumes the more specific attributes, Direct Device, Indirect Device, Using Device, and Using
Access Device. The more specific attributes should be used instead of Procedure Device, if possible.
For example,
276272002 | Catheter procedure (procedure) | (http://snomed.info/id/276272002)has Procedure device, Catheter,
device (physical object)

Procedure device
The attribute values in the Procedure Device hierarchy include Device (physical object) and its
descendants.
There are a limited number of drug delivery devices in SNOMED CT. These concepts descend from Drug-
device combination product (product) which is a descendant of both Device (physical object) and
Pharmaceutical / biologic product (product). Although they carry the hierarchy tag of (product), they are
acceptable values for attributes in the Procedure Device attribute hierarchy.

Procedure morphology
Procedure Morphology is used to specify the morphology, or abnormal structure, involved in a procedure. It is used
when defining general concepts that subsume direct and indirect morphology. It subsumes the more specific
attributes, Direct and Indirect Morphology. These should be used, if possible.

Morphologically abnormal structures

Hematoma, calculus, foreign body, blood clot, embolus, and some other morphologies are not strictly
body structures. But, they are included in the body structure hierarchy under morphologically abnormal
structure and are valid values for the Procedure Morphology attributes.

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Procedure site
Procedure Site describes the body site acted on or affected by a procedure.
Relatively few concepts are modeled using Procedure Site. It is used to model the site for high-level grouping-type
procedure concepts. It is most likely used for concepts that do not require a 260686004 | Method (attribute) | (
http://snomed.info/id/260686004) and 129264002 | Action (qualifier value) | (http://snomed.info/id/129264002) pair. It is not
required in order for the classifier to work properly.
363704007 | Procedure site (attribute) | (http://snomed.info/id/363704007) subsumes the more specific attributes,
405813007 | Procedure site - Direct (attribute) | (http://snomed.info/id/405813007), which is the site directly acted upon,
and 405814001 | Procedure site - Indirect (attribute) | (http://snomed.info/id/405814001), which is the site indirectly
acted upon. The more specific attributes should be used if possible (see Procedure Site - Direct and Procedure Site -
Indirect explained below).
For example,
118839001 | Procedure on colon (procedure) | (http://snomed.info/id/118839001) has Procedure site of Colon
structure (body structure)

Procedure site
Procedures are not necessarily categorized by site.

Use of Structure of <anatomical structure> vs. Entire <anatomical structure> as value of the Procedure site
attributes
Structure of <anatomical structure> rather than Entire <anatomical structure> should be used as the value for
procedure site attributes, except where the procedure FSN explicitly specified that the entire structure is the object
of the procedure.
For example,
23968004 | Excision of colon (procedure) | (http://snomed.info/id/23968004) has 405813007 | Procedure site -
Direct (attribute) | (http://snomed.info/id/405813007) of 71854001 | Colon structure (body structure) | (
http://snomed.info/id/71854001)

26390003 | Total colectomy (procedure) | (http://snomed.info/id/26390003)has 405813007 | Procedure site -

Direct (attribute) | (http://snomed.info/id/405813007) of 302508007 | Entire colon (body structure) | (http://snomed.
info/id/302508007)

Procedure site - direct

Procedure Site - Direct is used when the action of the procedure is directly aimed a t anatomical or acquired body
structure or site, rather than something else located there (e.g. a device), i.e. when the 260686004 | Method
(attribute) | (http://snomed.info/id/260686004) is 129303008 | Removal - action (qualifier value) | (http://snomed.info/id
/129303008) or one of its subtypes (Excision, Surgical biopsy, or etc.). Removal of tissue lesions (cysts, tumors, or etc.)
are considered to be removal of the site and should also use 405813007 | Procedure site - Direct (attribute) | (
http://snomed.info/id/405813007).

For example,
54321008 | Cardiac flow imaging (procedure) | (http://snomed.info/id/54321008) has 405813007 | Procedure site
- Direct (attribute) | (http://snomed.info/id/405813007) of Coronary artery structure (body structure)

Procedure site - indirect

Procedure site - Indirect is used to specify an anatomical site in which a procedure takes place when that
anatomical site is not the direct object of the procedure action. The direct object of the action may be a device, a
substance, or a morphologic abnormality that is not a part of the tissue structure of the anatomical site in which it is
located, such as a calculus, thrombus, or foreign body. Thus, 405814001 | Procedure site - Indirect (attribute) | (
http://snomed.info/id/405814001) is typically found in a relationship group with a second, "direct" attribute-value
relationship, such as a Direct morphology, Direct substance, or Direct device.

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For example,
405433000 | Removal of catheter from brachial vein (procedure) | (http://snomed.info/id/405433000) has:
Method, Removal - action (qualifier value)
Procedure site - Indirect, Structure of brachial vein (body structure)
Direct device, Venous catheter (physical object)

371005009 | Removal of calculus of urinary bladder (procedure) | (http://snomed.info/id/371005009) has:

Direct morphology, Calculus (morphologic abnormality)
Method, Removal - action (qualifier value)
Procedure site - Indirect, Urinary bladder structure (body structure)

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Recipient category
Recipient Category specifies the type of individual or group upon which the action of the procedure is performed.
For example,
105455006 | Donor for medical or surgical procedure (person) | (http://snomed.info/id/105455006) has Recipient
Category, Donor if the subject of the record is the Blood product donor (person).
This can be used in blood banking procedures to differentiate the donor vs the recipient of blood products.

Recipient category
It is not used for a procedure where the subject of the procedure is someone other than the subject of
record.

Revision status
Revision Status refers to another procedure performed on the same site for the same condition. A procedure
without a revision status is considered to be performed for the first time. A revision procedure can be modeled with
a Revision status (attribute) of revision - value (qualifier value).
For example,
128323000 | Revision of implant (procedure) | (http://snomed.info/id/128323000) has Revision status, revision -
value (qualifier value)

Using access device

Using Access Device specifies the instrument or equipment used to access the site of a procedure.
For example,
301761003 | Arthroscopic synovial biopsy (procedure) | (http://snomed.info/id/301761003) has Using access
device, Arthroscope, device (physical object)

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Using device
Using Device refers to the instrument or equipment utilized to execute an action. It is used when the device is
actually used to carry out the action, that is the focus of the procedure. If the device is simply the means to access
the site of the procedure, then Using Access Device is the appropriate attribute.
For example,
51064005 | Core needle biopsy of larynx (procedure) | (http://snomed.info/id/51064005) has Using device, Core
biopsy needle, device (physical object)

Using energy
Using Energy refers to the energy used to execute an action.
For example,
65952009 | Gamma ray therapy (procedure) | (http://snomed.info/id/65952009) has Using energy, Gamma
radiation (physical force)

Using substance
Using Substance describes the Substance used to execute the action of a procedure. It is not the substance on
which the procedure's method directly acts, the Direct Substance.
For example,
285754008 | Contrast radiography of esophagus (procedure) | (http://snomed.info/id/285754008) has Using
substance, Contrast media (substance)

Evaluation Procedure
The following defining attributes are unique in the context of the 386053000 |Evaluation procedure (procedure)|
subhierarchy. Many of these attributes (e.g., Component, Scale type) are used to define Observable entity concepts.
Evaluation procedures may use the attributes below in addition to those attributes allotted to the 71388002 |
Procedure (procedure) | (http://snomed.info/id/71388002) hierarchy (see Procedure Attributes Summary page). All of
the attributes for Evaluation procedure concepts are grouped. Also see 'Observable Entity vs. Evaluation Procedure'
at Observable Entity.

Component
Component refers to what is being observed or measured by a procedure.
For example,
442165003 | Quantitative measurement of polychlorinated biphenyl in blood specimen using gas
chromatography (procedure) | (http://snomed.info/id/442165003) has 246093002 | Component (attribute) | (
http://snomed.info/id/246093002) of 42001007 | Polychlorinated biphenyl (substance) | (http://snomed.info/id
/42001007)

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Has specimen
Has Specimen indicates the type of specimen on which a measurement or observation is performed.
For example,
442165003 | Quantitative measurement of polychlorinated biphenyl in blood specimen using gas
chromatography (procedure) | (http://snomed.info/id/442165003) uses 116686009 | Has specimen (attribute) | (
http://snomed.info/id/116686009) of 119297000 | Blood specimen (specimen) | (http://snomed.info/id/119297000)

Measurement method
Measurement Method specifies the method by which an evaluation procedure is performed. It provides additional
specificity. For measurement procedures, the 260686004 | Method (attribute) | (http://snomed.info/id/260686004) is
given the value 129266000 | Measurement - action (qualifier value) | (http://snomed.info/id/129266000). No concept
can be defined with a 370129005 | Measurement method (attribute) | (http://snomed.info/id/370129005) unless it is
being used to refine a 260686004 | Method (attribute) | (http://snomed.info/id/260686004) that has a value of
129266000 | Measurement - action (qualifier value) | (http://snomed.info/id/129266000) or one of its subtypes that is
also specified in the concept definition. That is, use of 370129005 | Measurement method (attribute) | (http://snomed.
info/id/370129005) must be in addition to a 260686004 | Method (attribute) | (http://snomed.info/id/260686004) of
129266000 | Measurement - action (qualifier value) | (http://snomed.info/id/129266000) or one of its subtypes. Also, the
370129005 | Measurement method (attribute) | (http://snomed.info/id/370129005) and its value must be grouped with
the 260686004 | Method (attribute) | (http://snomed.info/id/260686004) and its value of the concept or subtype of
129266000 | Measurement - action (qualifier value) | (http://snomed.info/id/129266000).
For example,
442165003 | Quantitative measurement of polychlorinated biphenyl in blood specimen using gas
chromatography (procedure) | (http://snomed.info/id/442165003) has a 370129005 | Measurement method
(attribute) | (http://snomed.info/id/370129005) of 2842000 | Gas chromatography measurement (procedure) | (
http://snomed.info/id/2842000)

Property
Property specifies the kind of property (quality or characteristic) being measured.
For example,

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19165008 | Measurement of limb length (procedure) | (http://snomed.info/id/19165008) has a 370130000 |

Property (attribute) | (http://snomed.info/id/370130000) of 410668003 | Length property (qualifier value) | (
http://snomed.info/id/410668003)

Scale type
Scale Type refers to the scale of the result of an observation of a diagnostic test.
For example,
442165003 | Quantitative measurement of polychlorinated biphenyl in blood specimen using gas
chromatography (procedure) | (http://snomed.info/id/442165003) has 370132008 | Scale type (attribute) | (
http://snomed.info/id/370132008) of 30766002 | Quantitative (qualifier value) | (http://snomed.info/id/30766002)

Time aspect
Time Aspect specifies temporal relationships for a measurement procedure. While this attribute has been approved,
guidelines for its implementation await development.

Further clarification
An evaluation procedure may evaluate a property of a component , or a property may be the sole focus of the
method.
For example of an evaluation procedure evaluating a property of a component,
443834000 | Quantitative measurement of mass concentration of bismuth in urine specimen (procedure) | (
http://snomed.info/id/443834000) has 370130000 | Property (attribute) | (http://snomed.info/id/370130000) of
118539007 | Mass concentration (property) (qualifier value) | (http://snomed.info/id/118539007) and 246093002 |
Component (attribute) | (http://snomed.info/id/246093002) of 23172004 | Bismuth (substance) | (http://snomed.info
/id/23172004)

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For example where property may be the sole focus of the method,
78888000 | Osmolality measurement, urine (procedure) | (http://snomed.info/id/78888000)

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Surgical Procedure
The following defining attribute is unique to Surgical procedures. Surgical procedures may also use the attributes in
the Procedure Attributes Summary table from the HRCM (see also Procedure Defining Attributes page).

Surgical approach
Surgical Approach specifies the directional, relational, or spatial access to the site of a surgical procedure. The range
for Surgical Approach is descendants of 103379005 | Procedural approach (qualifier value) | (http://snomed.info/id
/103379005)

172883004 | Intranasal ethmoidectomy (procedure) | (http://snomed.info/id/172883004) has Surgical approach,

Intranasal approach (qualifier value)

Administration of Substance via Specific Route Procedure

In addition to attributes applicable to general procedures, the subhierarchy of |Administration of substance via
specific route (procedure)| also includes the |Route of administration (attribute)|.

Route of administration
Route of administration represents the route by which a procedure introduces a substance into the body. The
domain for this attribute is descendants of 433590000 | Administration of substance via specific route (procedure) | (
http://snomed.info/id/433590000). The range involves subtypes of 284009009 |Route of administration value (qualifier
value)|. When using this attribute, an additional attribute of |Procedure site - indirect| should be modeled and
grouped with the |Route of administration (attribute)|. While the values for these two attributes may be similar and
seem redundant, their presence is necessary for consistent inheritance.
For example,
410572008 | Intravitreal steroid injection (procedure) | (http://snomed.info/id/410572008) has the | Route of
administration (attribute) | (http://snomed.org/fictid#) of Intravitreal route (qualifier value)

Figure 1: Stated view of 410572008 |Intravitreal steroid injection (procedure)|

While the values for the |Procedure site - Indirect| and |Route of administration| attributes may be similar and seem
redundant, their presence is necessary for consistent subsumption.

Route of administration (qualifier value) Body structure value of Procedure site - Indirect

Intravenous route Venous structure

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Route of administration (qualifier value) Body structure value of Procedure site - Indirect

Oral route Mouth region structure

Table 1: Examples of complementary values of Route of administration and Procedure site - Indirect

Procedure Naming Conventions

When possible, the FSN for a procedure should name the action of the procedure (the method) first, and then the
object that the action acts directly upon. However, the structure of FSNs can vary.
For example,
Transurethral prostatectomy (procedure)
Colpopexy by abdominal approach (procedure)
Total hysterectomy via vaginal approach (procedure)
Anterior decompression of fracture of spine (procedure)
Including the approach is not relevant in some cases, though where more than one option exists, it is valid to do so.
Often the approach is indicated at the beginning of the FSN. Again, the naming is determined on a case-by-case
basis but often follows one of the two following patterns:
FSN: <Y> approach <X> procedure e.g. Transurethral prostatectomy (procedure)
OR
FSN: <X> procedure via <Y> approach e.g.173822004 |Diagnostic gastroscopy via stoma (procedure)|

Surgical procedures
Surgical procedures: Use "via" for route/approach and "using" for device.

Anatomical site
An anatomical site is the direct object of the action. The word/s naming the site should follow the word(s) naming
the action.
For example,
175253007 | Repair of pulmonary artery (procedure) | (http://snomed.info/id/175253007). The action is repair and
the site is pulmonary artery.

Device
A device is the direct object of the action. The word(s) naming the device should follow the word/s naming the
action. If there is a site that is not the direct object of the action, the word(s) naming it, should come after the word
(s) naming the device.
For example,
392247006 | Insertion of catheter into artery (procedure) | (http://snomed.info/id/392247006). The action is
insertion, the direct object is catheter, and the indirect site is artery.

Substance
A substance is the direct object of the action. The word(s) that name the substance should follow the words that
name the action. If there is a site that is not the direct object of the action, the word/s naming it should follow the
word(s) naming the substance.
For example,

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427258004 | Injection of hormone into subcutaneous tissue (procedure) | (http://snomed.info/id/427258004).

Injection is the action, hormone is the direct object, and subcutaneous tissue is the indirect site.

Morphologic abnormality
A morphologic abnormality is the direct object of the action. The morphology term should follow the action term. If
there is a site, it should follow the morphology term.
For example,
41180005 | Excision of cyst of breast (procedure) | (http://snomed.info/id/41180005). Excision is the action, the
direct object is the morphologic abnormality cyst, and breast is the site.
175376008 | Operation on aneurysm of carotid artery (procedure) | (http://snomed.info/id/175376008). The action
is operation, the direct object is the morphologic abnormality aneurysm, and the site is carotid artery.

Past tense verbs and sentence types

A procedure concept should be a noun phrase that names the procedure. It should not contain information that it
was done, or is to be ordered, carried out, or planned.
Past tense verbal phrases should not be used to name procedures, since past tense invokes a temporal
context, i.e the procedure was done in the past. Any existing concepts with past tense verbs, should be
moved to the Situation with explicit context hierarchy.
Sentence function types, i.e. imperative, declarative, interrogative, or exclamatory are disallowed in procedure
concepts.
Acceptable example,
11227005 | Excision of ganglion of tendon sheath of hand (procedure) | (http://snomed.info/id/11227005). This is
an acceptable FSN expressed with a noun phrase.
Unacceptable example,
Hand tendon ganglion excised indicates the procedure was done, as a past tense declarative statement. This
should be in the Situation with explicit context hierarchy, not the Procedure hierarchy.

Chemotherapy Regime/Therapy Naming Conventions

Chemotherapy regimens, which are internationally recognized and implemented, are acceptable content and may
be added to the (regime/therapy) hierarchy as subtypes of 716872004 | Antineoplastic chemotherapy regimen
(regime/therapy) | (http://snomed.info/id/716872004).
Trade names, which are indicated by an acronym, e.g. ABVD chemotherapy regimen, where A represents trade
name Adriamycin®, should not be spelled out, but may be referenced in the acronym used to describe the regimen.
Generic drug names are not capitalized, i.e. all lower case, and should represent the International Non-proprietary
Name (INN) of the substance.

Examples,
ABVD chemotherapy regimen. A represents the trade name Adriamycin® (INN = doxorubicin):
FSN: Doxorubicin, bleomycin, vinblastine and dacarbazine chemotherapy regimen (regime/therapy)
PT: ABVD chemotherapy regimen
Synonym: Doxorubicin, bleomycin, vinblastine and dacarbazine chemotherapy regimen
Synonym: ABVD chemotherapy protocol
R-CHOP chemotherapy regimen. H represents the non-INN generic name hydroxydaunomycin (INN = doxorubicin)
and O represents the trade name Oncovin® (INN = vincristine):
FSN: Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy regimen (regime
/therapy)
PT: R-CHOP chemotherapy regimen

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Synonym: Rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone chemotherapy regimen

Synonym: R-CHOP chemotherapy protocol

Clinical Imaging Procedure Naming Conventions

Almost all imaging procedures can be unambiguously expressed in a number of ways. There is a balance between
flexibility in language and efficiency in terminology maintenance. Consequently, all variants for imaging modalities
are not routinely included in SNOMED CT. Submissions for additional descriptions must be justified explicitly.
At a minimum, procedures are ordinarily expressed with the modality and body site. Existing content may have
inconsistencies, but new content should following the naming conventions that follow.

The use of near synonyms is acceptable for clinical imaging procedures:

For example,
79516005 | Renal arteriography (procedure) | (http://snomed.info/id/79516005) has the synonym renal
angiography
726077005 | Computed tomography arteriography of bronchial artery (procedure) | (http://snomed.
info/id/726077005) has the synonym CT angiography of bronchial artery

709552006 | Computed tomography angiography of iliac artery (procedure) | (http://snomed.info/id

/709552006) has the synonym CT angiogram of iliac artery

X-ray

Under revision
There is inconsistency with naming Radiology of X vs X-ray of X and modeling of X-ray concepts.
Preliminary analysis has been completed and a new approach recommended. Remodeling is pending.

Approach 1: Radiography of X
FSN: Radiography of X (procedure)
PT: Radiography of X
For example,
49345004 | Radiography of hand (procedure) | (http://snomed.info/id/49345004)
Approach 2: X-ray of X
FSN: X-ray of X (procedure)
PT: X-ray of X
For example,
426581005 | X-ray of both feet (procedure) | (http://snomed.info/id/426581005)
Diagnostic radiography
363680008 | Radiographic imaging procedure (procedure) | is at the top-level of the hierarchy of imaging
procedures utilizing X-rays. The phrase diagnostic radiography is allowed as an FSN of subtypes of radiographic
imaging procedure.
For example,
66596009 | Diagnostic radiography for foreign body detection and localization (procedure) | (http://snomed.info
/id/66596009)

Inactivated concept

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Diagnostic radiologic examination (procedure) had a synonym of X-ray. It may have been interpreted
more narrowly, because of the potential for a narrower interpretation of radiologic vs. radiographic and
diagnostic.

Modeling: New content requests

An X-ray concept may have the action, 312254007 | Plain X-ray imaging - action (qualifier value) | (
http://snomed.info/id/312254007) or the broader supertype action, 278110001 | Radiographic imaging -
action (qualifier value) | (http://snomed.info/id/278110001). A s ubmitter should clearly identify which of the
actions is appropriate.

Ultrasonography
Ultrasonography
FSN: Ultrasonography of X (procedure)
PT: Ultrasonography of X
SYN: Ultrasound scan of X
SYN: Ultrasound of X
For example,
709590000 | Ultrasonography of perineum (procedure) | (http://snomed.info/id/709590000)
FSN: Ultrasonography of perineum (procedure)
PT: Ultrasonography of perineum
SYN: Ultrasound scan of perineum
SYN: Ultrasound of perineum
Doppler ultrasonography
FSN: Doppler ultrasonography of X (procedure)
PT: Doppler ultrasonography of X
SYN: Doppler ultrasound scan of X
SYN: Doppler ultrasound of X
For example,
710306004 | Doppler ultrasonography of venous structure (procedure) | (http://snomed.info/id/710306004)
FSN: Doppler ultrasonography of venous structure (procedure)
PT: Doppler ultrasonography of vein
SYN: Doppler ultrasound scan of vein
SYN: Doppler ultrasound of vein
Obstetric ultrasonography
An obstetric ultrasound may require a complex description. However, the same rules apply, as follows:
FSN: Obstetric ultrasonography of X (procedure)
PT: Obstetric ultrasonography of X
SYN: Obstetric ultrasound scan of X
SYN: Obstetric ultrasound of X
For example,
169670003 | Antenatal ultrasound scan at 17-22 weeks (procedure) | (http://snomed.info/id/169670003)

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FSN: Antenatal ultrasound scan at 17-22 weeks (procedure)

PT: Antenatal ultrasound scan at 17-22 weeks

Computed Tomography (CT)

Exception
CT is an exception to the rule that all abbreviations should have their expanded form in parentheses in
descriptions.

Axial
Legacy issues: Existing computerized tomography concepts, will be renamed consistently when the
Quality Initiative tackles the cleanup of procedures.
Requests for new descriptions with computerized axial tomography (CAT) are not acceptable. The axial
part of the phrase is no longer accurate because there are other techniques that also create images on
multiple planes or axes.
Scan
Computed tomography descriptions do not routinely include computed tomography scan of X.
The word scan is not systematically added in new descriptions and should not be included in preferred
terms. However, specific requests to add descriptions with the word scan, are not denied.
Computerized axial tomography scan of X is considered obsolete and should not be added as a new
description.

Computed tomography
FSN: Computed tomography of X (procedure)
PT: CT of X
SYN: Computed tomography of X
For example,
241566009 | Computed tomography of elbow (procedure) | (http://snomed.info/id/241566009)
FSN: Computed tomography of elbow (procedure)
PT: CT of elbow
SYN: Computed tomography of elbow
Computed tomography angiography
FSN: Computed tomography angiography of X (procedure)
PT: CT angiography of X
SYN: CT angiogram of X
SYN: Computed tomography angiography of X
For example,
419559003 | Computed tomography angiography of renal artery (procedure) | (http://snomed.info/id/419559003)
FSN: Computed tomography angiography of renal artery (procedure)
PT: CT angiography of renal artery
SYN: Computed tomography angiography of renal artery
Computed tomography venography
FSN: Computed tomography venography of X (procedure)

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PT: CT venography of X
SYN: CT venogram of X
SYN: Computed tomography venography of X
For example,
432842007 | Computed tomography venography of intracranial vein (procedure) | (http://snomed.info/id
/432842007)

FSN: Computed tomography venography of intracranial vein (procedure)

PT: CT venography of intracranial vein
SYN: Computed tomography venography of intracranial vein

Venography
Venography may simply be a timing phase of angiography. It is agreed that venography may be a useful
term in an FSN, i.e. there may be a meaningful technique difference between simple angiography and
purposeful venography.

Computed tomography arthrography

FSN: Computed tomography arthrography of X (procedure)
PT: CT arthrography of X
SYN: CT arthrogram of X
SYN: Computed tomography arthrography of X
For example,
418940000 | Computed tomography arthrography of intratarsal joint (procedure) | (http://snomed.info/id
/418940000)

FSN: Computed tomography arthrography of intratarsal joint (procedure)

PT: CT arthrogram of intratarsal joint
SYN: CT arthrography of intratarsal joint

Magnetic Resonance Imaging (MRI)

Exception
MRI and MR are exceptions to the rule that all abbreviations should have their expanded form in
parentheses in descriptions.

Magnetic resonance imaging

Descriptions:
FSN: Magnetic resonance imaging of X (procedure)
PT: MRI of X
SYN: Magnetic resonance imaging of X
For example,
6007000 | Magnetic resonance imaging of chest (procedure) | (http://snomed.info/id/6007000)
FSN: Magnetic resonance imaging of chest (procedure)
PT: MRI of chest
SYN: Magnetic resonance imaging of chest

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Magnetic resonance angiography

Descriptions:
FSN: Magnetic resonance angiography of X (procedure)
PT: Magnetic resonance angiography of X
SYN: Magnetic resonance angiogram of X
SYN: MR angiography of X
For example,
432103005 | Magnetic resonance angiography of carotid artery (procedure) | (http://snomed.info/id/432103005)
FSN: Magnetic resonance angiography of carotid artery (procedure)
PT: Magnetic resonance angiography of carotid artery
SYN: Magnetic resonance angiogram of carotid artery
SYN: MR angiography of carotid artery
Magnetic resonance venography
Descriptions:
FSN: Magnetic resonance venography of X (procedure)
PT: Magnetic resonance venography of X
SYN: Magnetic resonance venogram of X
SYN: MR venography of X
For example,
21101000087100 | Magnetic resonance venography of limb (procedure) | (http://snomed.info/id/21101000087100)
FSN: Magnetic resonance venography of limb (procedure)
PT: Magnetic resonance venography of extremity
SYN: Magnetic resonance venography of limb
Magnetic resonance arthrography
Descriptions:
FSN: Magnetic resonance arthrography of X (procedure)
PT: Magnetic resonance arthrography of X
SYN: Magnetic resonance arthrogram of X
SYN: MR arthrography of X
For example,
19741000087109 | Magnetic resonance arthrography of right knee (procedure) | (http://snomed.info/id
/19741000087109)

FSN: Magnetic resonance arthrography of right knee (procedure)

PT: Magnetic resonance arthrography of right knee
SYN: MR arthrography of right knee

Contrast for Imaging

It is essential to express when contrast is part of a procedure and that descriptions are constructed consistently.
For example,
702501008 | Computed tomography of knee with contrast (procedure) | (http://snomed.info/id/702501008)
FSN: Computed tomography of knee with contrast (procedure)
PT: CT of knee with contrast

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SYN: Computed tomography of knee with contrast

Exception
Fluoroscopic angiography and fluoroscopic-guided angiography procedures do not require with contrast.
For example,
418867007 | Fluoroscopic angiography of abdominal vascular structure (procedure) | (http://snomed.
info/id/418867007)

Although vascular contrast and other contrast are regularly used in imaging procedures, it is agreed that there is no
need to specify vascular contrast for procedures involving the vasculature.
For example,
431326009 | Computed tomography of neck with contrast (procedure) | (http://snomed.info/id/431326009)
Unacceptable example,
CT of neck with vascular contrast
It is agreed that it is unnecessary to add the word media to contrast.
It is agreed that the link word to associate the contrast use with the procedure is with not for or etc.

Contrast
There is a suggestion that additional concept detail is required when it is necessary to know the more
precise nature of contrast (e.g. iodinated with various osmolalities, barium, or gas).

Imaging without contrast

Although considered a negation, this term is used in clinical records. Without contrast imaging procedures are
acceptable.
For example,
566341000119106 | Computed tomography of ankle without contrast (procedure) | (http://snomed.info/id
/566341000119106)

FSN: Computed tomography of ankle without contrast (procedure)

PT: CT ankle without contrast
SYN: Computed tomography of ankle without contrast

Without contrast
There is a case for explicitly adding a concept qualification when naming procedures that are explicitly
performed without contrast.
In the UK and Australia, it was reported that there are no procedures that specify without contrast pre-
coordinated in the national subset. With this information, implementation guidance may be provided.

Unacceptable concept qualification

With and without and With or without imaging concepts are not acceptable due to ambiguity. Two concepts should
be used to express these separately.

Imaging Guided Procedures

There are numerous procedures where the imaging component is considered a supplemental or secondary
technique to help accomplish the primary goal. The pattern is:
Procedure using guidance

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FSN: Y (procedure) using (DI Modality guidance) (procedure)

PT: (DI Modality) guided Y (procedure)
SYN: Y (procedure) using (DI Modality guidance)
For example,
407971000119109 | Percutaneous needle biopsy of liver using computed tomography guidance (procedure) | (
http://snomed.info/id/407971000119109)

FSN: Percutaneous needle biopsy of liver using computed tomography guidance (procedure)
PT: CT guided biopsy of liver
SYN: Percutaneous needle biopsy of liver using computed tomography guidance
Computed tomography guided procedure
FSN: Y using computed tomography guidance (procedure)
PT: CT guided Y
SYN: Y using computed tomography guidance
For example,
431864000 | Injection using computed tomography guidance (procedure) | (http://snomed.info/id/431864000)
FSN: Injection using computed tomography guidance (procedure)
PT: CT guided injection
SYN: Injection using computed tomography guidance
Fluoroscopy guided procedure
FSN: Y using fluoroscopic guidance (procedure)
PT: Fluoroscopy guided Y
SYN: Y using fluoroscopic guidance
For example,
430278000 | Biopsy using fluoroscopic guidance (procedure) | (http://snomed.info/id/430278000)
FSN: Biopsy using fluoroscopic guidance (procedure)
PT: Biopsy using fluoroscopic guidance
SYN: Fluoroscopic guidance for biopsy

Fluoroscopic guidance
The term fluoroscopic Y is interpreted as Y using fluoroscopic guidance (procedure). Procedures such as
432540009 | Biopsy of wrist using fluoroscopic guidance (procedure) | (http://snomed.info/id/432540009) are
subtypes of Fluoroscopy (procedure).

(See also Fluoroscopy and Fluoroscopic Imaging page)

Magnetic resonance imaging guided procedure
FSN: Y using magnetic resonance imaging guidance (procedure)
PT: MRI guided Y (procedure)
SYN: Y using magnetic resonance imaging guidance
For example,
433008009 | Core needle biopsy of breast using magnetic resonance imaging guidance (procedure) | (
http://snomed.info/id/433008009)

FSN: Core needle biopsy of breast using magnetic resonance imaging guidance (procedure)
PT: MRI guided core needle biopsy of breast

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SYN: Core needle biopsy of breast using magnetic resonance imaging guidance
Ultrasonography guided procedure
FSN: Y using ultrasonographic guidance (procedure)
PT: Ultrasonography guided Y
SYN: Y using ultrasonographic guidance
For example,
710790002 | Puncture and aspiration using ultrasonographic guidance (procedure) | (http://snomed.info/id
/710790002)

FSN: Puncture and aspiration using ultrasonographic guidance (procedure)

PT: Ultrasonography guided puncture and aspiration
SYN: Puncture and aspiration using ultrasonographic guidance
X-ray guided procedure
FSN: Y using X-ray guidance (procedure)
PT: X-ray guided Y
SYN: Y using X-ray guidance
For example,
718674009 | Injection of steroid using X-ray guidance (procedure) | (http://snomed.info/id/718674009)
FSN: Injection of steroid using X-ray guidance (procedure)
PT: X-ray guided steroid injection
SYN: Injection of steroid using X-ray guidance

Fluoroscopy and Fluoroscopic Imaging

Simple fluoroscopy
Simple fluoroscopy is real time imaging (usually on TV monitors/image intensifiers) of a body part or system. Only
rarely is it an imaging process alone (without use of contrast or some interventional procedure). Fluoroscopy is
most often used to guide or direct a primary procedure/purpose.
The usual convention in clinical practice is to ignore the fluoroscopic element and refer to a procedure entirely by
the primary component, e.g. angiography. However, this is unacceptable in SNOMED CT, where the imaging
component must be explicitly described. SNOMED CT uses the adjectival form, i.e. fluoroscopic arteriography in the
FSN; the noun, i.e. fluoroscopic arteriogram, is acceptable as a synonym.
FSN: Fluoroscopy of X (procedure)
PT: Fluoroscopy of X
SYN: Fluoroscopy - X
For example,
169005008 | Fluoroscopy of esophagus (procedure) | (http://snomed.info/id/169005008)
FSN: Fluoroscopy of esophagus (procedure)
PT: Fluoroscopy of esophagus
SYN: Fluoroscopy - esophagus
Fluoroscopic guidance
FSN: Y using fluoroscopic guidance (procedure)
PT: Fluoroscopy guided Y
SYN: Y using fluoroscopic guidance
For example,

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710293001 | Colonoscopy using fluoroscopic guidance (procedure) | (http://snomed.info/id/710293001)

FSN: Colonoscopy using fluoroscopic guidance (procedure)
PT: Fluoroscopy guided colonoscopy
SYN: Colonoscopy using fluoroscopic guidance

Fluoroscopic guidance
Fluoroscopic Y is interpreted as Y using fluoroscopic guidance (procedure). Such procedures are subtypes
of fluoroscopy (procedure).
For example,
432540009 | Biopsy of wrist using fluoroscopic guidance (procedure) | (http://snomed.info/id
/432540009)

Fluoroscopic arteriography
FSN: Fluoroscopic arteriography of X (procedure)
PT: Fluoroscopic arteriography of X
SYN: Fluoroscopic arteriogram of X
SYN: Fluoroscopic angiography of X
SYN: Fluoroscopic angiogram of X
For example,
16051000087102 | Fluoroscopic arteriography of right cervical vertebral artery (procedure) | (http://snomed.info
/id/16051000087102)

FSN: Fluoroscopic arteriography of right cervical vertebral artery (procedure)

PT: Fluoroscopic arteriography of right cervical vertebral artery
SYN: Fluoroscopic arteriogram of right cervical vertebral artery
SYN: Fluoroscopic angiography of right cervical vertebral artery
SYN: Fluoroscopic angiogram of right cervical vertebral artery
Fluoroscopic venography
FSN: Fluoroscopic venography of X
PT: Fluoroscopic venography of X
SYN: Fluoroscopic venogram of X
For example,
392491000119105 | Fluoroscopic venography of right extremity (procedure) | (http://snomed.info/id
/392491000119105)

FSN: Fluoroscopic venography of right extremity (procedure)

PT: Fluoroscopic venography of right extremity
SYN: Fluoroscopic venogram of right extremity
Fluoroscopic arthrography
FSN: Fluoroscopic arthrography of X (procedure)
PT: Fluoroscopic arthrography of X
SYN: Fluoroscopic arthrogram of X
For example,
723775001 | Fluoroscopic arthrography of right sacroiliac joint (procedure) | (http://snomed.info/id/723775001)
FSN: Fluoroscopic arthrography of right sacroiliac joint (procedure)

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PT: Fluoroscopic arthrography of right sacroiliac joint

SYN: Fluoroscopic arthrogram of right sacroiliac joint
Dual energy X-ray photon absorptiometry
FSN: Dual energy X-ray photon absorptiometry of X (procedure)
PT: Dual energy X-ray photon absorptiometry of X
SYN: DXA of X
SYN: DEXA of X
For example,
723193006 | Dual energy X-ray photon absorptiometry of vertebral column (procedure) | (http://snomed.info/id
/723193006)

FSN: Dual energy X-ray photon absorptiometry of vertebral column (procedure)

PT: Dual energy X-ray photon absorptiometry of vertebral column
SYN: DXA of vertebral column
SYN: DEXA of vertebral column

Positron emission tomography (procedure)

FSN: Positron emission tomography of X (procedure)
PT: PET of X
SYN: Positron emission tomography of X
For example,
702767007 | Positron emission tomography of whole body (procedure) | (http://snomed.info/id/702767007)
FSN: Positron emission tomography of whole body (procedure)
PT: PET of whole body
SYN: Positron emission tomography of whole body

Single photon emission computerized tomography (procedure)

FSN: Single photon emission computed tomography of X (procedure)
PT: Single photon emission computed tomography of X
SYN: SPECT of X
For example,
709549003 | Single photon emission computed tomography of heart (procedure) | (http://snomed.info/id
/709549003)

FSN: Single photon emission computed tomography of heart (procedure)

PT: Single photon emission computed tomography of heart
SYN: SPECT of heart

Multi-modality Imaging: PET/CT and SPECT/CT

There are very few imaging procedures which are truly multi-modality procedures. Two procedures are usually
conducted in parallel, rather than as one. Positron emission tomography with computed tomography (PET/CT) and
Single photon emission computed tomography with computed tomography (SPECT/CT), however, are produced by
one piece of equipment, possibly by a single technician, but with multiple imaging energies.
Positron emission tomography with computed tomography
FSN: Positron emission tomography with computed tomography of X (procedure)
PT: PET CT of X

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SYN: Positron emission tomography with computed tomography of X

For example,
16554361000119106 | Positron emission tomography with computed tomography of brain (procedure) | (
http://snomed.info/id/16554361000119106)

FSN: Positron emission tomography with computed tomography of brain (procedure)

PT: PET CT of brain
SYN: Positron emission tomography with computed tomography of brain
Single photon emission computed tomography with computed tomography
FSN: Single photon emission computed tomography with computed tomography of X (procedure)
PT: Single photon emission computed tomography with computed tomography of X
SYN: SPECT CT of X
For example,
16534151000119105 | Single photon emission computed tomography with computed tomography of liver
(procedure) | (http://snomed.info/id/16534151000119105)
FSN: Single photon emission computed tomography with computed tomography of liver (procedure)
PT: Single photon emission computed tomography with computed tomography of liver
SYN: SPECT CT of liver

Nuclear Medicine (Radionuclide) Imaging

Nuclear medicine imaging uses radionuclides or radioisotopes.
Radionuclide scan
FSN: Radionuclide scan of X (procedure)
PT: Radionuclide scan of X
SYN: Radioisotope scan of X
For example,
710313004 | Radionuclide scan of peritoneal cavity (procedure) | (http://snomed.info/id/710313004)
FSN: Radionuclide scan of peritoneal cavity (procedure)
PT: Radionuclide scan of peritoneal cavity
SYN: Radioisotope scan of peritoneal cavity
Radionuclide scan using isotopes (with other agents)
FSN: Radionuclide scan of X using Y (procedure)
PT: Radionuclide scan of X using Y
SYN: Radioisotope scan of X using Y
For example,
710312009 | Radionuclide scan of perfusion of liver using technetium Tc^99m^ aggregated albumin
(procedure) | (http://snomed.info/id/710312009)
FSN: Radionuclide scan of perfusion of liver using technetium Tc^99m^ aggregated albumin
(procedure)
PT: Radionuclide scan of perfusion of liver using technetium Tc^99m^ aggregated albumin
SYN: Radioisotope scan of perfusion of liver using technetium Tc^99m^ aggregated albumin

Adjacent structures
Concepts which describe adjacent structures, imaged in one procedure, are acceptable.

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For example,
432672003 | Magnetic resonance imaging of pelvis and hip (procedure) | (http://snomed.info/id/432672003)

Unacceptable
Multiple procedures or a combination of different procedures in one concept are unacceptable.
Unacceptable examples,
Computed tomography angiography of aorta, abdomen, pelvis and lower limb
Ultrasonography of abdomen and ultrasonography of pelvis with transrectal ultrasonography
Ultrasonography of pelvis and obstetric ultrasonography with transvaginal ultrasonography
Ultrasonography of knee and Doppler ultrasonography of vein of lower limb

Imaging Adjustments for View, Projection, or Technique

It may be important, from both clinical and administrative perspectives, to capture variations or modifications of
imaging technique. The variations may impact correct acquisition and interpretation of images.
Examples of modifications include:
Axial (qualifier value)
Skyline projection (qualifier value)
Decubitus (qualifier value)

Post-coordination
Though these examples are qualifying values in SNOMED CT, they are not allowable for post-
coordination of diagnostic imaging procedures.

Measurement Procedure Naming Conventions

In SNOMED CT, measurement procedure is the preferred way of expressing a laboratory test. Measurement and
assay are synonymous in SNOMED CT. Naming conventions for measurement procedures are as follows:

General naming pattern: Action, Analyte, Specimen

Action
This is consistent with the general rule for the FSN for new procedure concepts.
Action (the Method) is named first, when possible
Modifier of the first component: Scale Method
Scale Method refines, and precedes the action in the naming order (Scale Method, Action)
Naming pattern: (Scale Method, Action), Analyte, Specimen
Analyte
This is also consistent with the general rule for FSNs for new procedure concepts.
Action (the Method) is named first followed by the object acted directly upon, when possible
Applying this convention to measurement procedures, the object being acted directly upon (measured) is the
analyte
Specimen
Modifier of third component: Timing

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Timing provides information and precedes specimen in the naming order (Timing, Specimen)

Word order for additional properties

Additional properties such as ratio, concentration, percentage, and count follow the action.

Screening
Measurements done by screening should be specified with by screening method, added at the end of the
description.
For example,
Measurement of substance X in Y specimen by screening method
The FSN should have measurement of X antibody by screening method, not X antibody assay by screening method.

Serologic and antibody

"Serology" and "serologic test" are ambiguous terms and should not be included in FSNs. These terms can be
included in the descriptions for antibody procedure concepts but cannot be included in the preferred term. The
existing content will be corrected in a future release.

Procedure Modeling

Procedure attribute hierarchies

SNOMED CT has attribute hierarchies for Procedure Site, Procedure Device, and Procedure Morphology. Each has
two sub-attributes to represent the direct and indirect objects. Procedure Device also has more specific attributes,
Using Device and Using Access Device. HRCM 2020-01-31

Author View of Ranges for 363704007 | Procedure site (attribute) | (http://snomed.info/id/363704007)

Range Constraint

<< 442083009 | Anatomical or acquired body structure (body structure) | (http://snomed.info/id/442083009)

HRCM 2020-01-31

Author View of Ranges for 405815000 | Procedure device (attribute) | (http://snomed.info/id/405815000)

Range Constraint

<< 49062001 | Device (physical object) | (http://snomed.info/id/49062001)

HRCM 2020-01-31

Author View of Ranges for 405816004 | Procedure morphology (attribute) | (http://snomed.info/id/405816004)

Range Constraint

<< 49755003 | Morphologically abnormal structure (morphologic abnormality) | (http://snomed.info/id/49755003)

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Observable Entity vs. Evaluation Procedure

The observable entity and evaluation procedure hierarchies have some of the same attributes. There is not and
should not be a one-to-one correspondence between the two hierarchies.
Concepts will not be duplicated between the observable entity hierarchy and procedure hierarchy, and requests for
such will not be added. While some users have indicated they want to use a procedure concept for ordering a test
and an observable concept for reporting the result, this is not an acceptable use case.
At this time, SNOMED CT contains some concepts in the procedure hierarchy which logically belong in the
observable entity hierarchy. It is noted that these concepts will likely move to the observable entity hierarchy in the
future. In addition, if we identify existing duplicate concepts between the two hierarchies, this will also be corrected.
The evaluation procedure hierarchy is currently classified under Procedure by method, with many immediate
children as follows:
Procedure by method (procedure)
Evaluation procedure (procedure); some children include:
Imaging (procedure)
Measurement procedure (procedure)
Physical examination assessment (procedure)

Evaluation procedures can be defined by Method = evaluation - action (qualifier value).

Subtypes of Evaluation-action (qualifier value) include:
Examination - action (qualifier value)
Imaging - action (qualifier value)
Measurement - action (qualifier value)
Monitoring - action (qualifier value)

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Spectroscopy - action (qualifier value)

Reason for Procedure

In general, the reason a procedure is ordered should not be precoordinated with the procedure, i.e. it should not
constrain the reporting of results. The reason that a procedure is ordered may influence the interpretation of the
results, but usually not the way the procedure is performed.
Unacceptable example,
Computed tomography angiography of chest with contrast for evaluation of pulmonary embolus (procedure)
Acceptable example including reason for procedure,
66596009 | Diagnostic radiography for foreign body detection and localization (procedure) | (http://snomed.info
/id/66596009)

Study
Procedures with the word study are unacceptable. They are ambiguous, as they imply context beyond
the execution of the procedure.

Primary vs Secondary Procedures

The meaning of primary and secondary, when describing a procedure, is open to interpretation. Consequently, the
concepts will be inactivated.
The interpretation of primary may be:
Not ever done before at this site
The first of multiple procedures, with two sub-meanings:
The first of planned multiple procedures, whether the plan is carried out or not
The first of multiple procedures that were not planned or foreseen, i.e it is only the first of multiple
procedures in retrospect
Examples of unacceptable descriptions,
Primary anterior decompression of cervical spinal cord (procedure)
Primary anterior excision of cervical intervertebral disc (procedure)
Primary arthrodesis of interphalangeal joint of toe (procedure)
Primary anterolateral excision of thoracic intervertebral disc (procedure)

"First" and “Subsequent” Procedures

"First" and “subsequent” procedures are not allowed, as they are inherently ambiguous and relative. While
administratively relevant, the additional descriptions of the procedure are not clinically relevant.
Unacceptable examples,
Antenatal first blood tests (procedure)
Antenatal subsequent blood tests (procedure)

Specific Procedure Modeling

Topic links
Surgical procedure (see page )
Surgical procedure (operation) vs. non-surgical action (see page )
Surgical repair (see page )

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Fistula (see page )

Plastic repair (see page )
Revision (see page )
Bilateral procedures (see page )
Regime/therapy (see page )
Endoscopy vs. endoscopic procedure (see page )
Centesis (see page )
Transplantation and grafting (see page )
Imaging guidance (see page )
Fluoroscopic guidance (see page )
Excision, incision, biopsy (see page )
Excision (see page )
Complete or total excision (see page )
Partial excision (see page )
Lesion or tissue (see page )
Excisional biopsy (see page )
Incision (see page )
Incisional biopsy (see page )
Division, lysis, transection, bisection (see page )
Division and lysis (see page )
Transection and bisection (see page )
Skeletal system (see page )
Osteotomy (see page )
Reduction and fixation of fractures (see page )
Immunization and vaccination (see page )
Encounter (see page )

Surgical procedure
A surgical procedure is defined as a procedure that involves intentional non-transient alteration of structures of the
body, and/or a procedure that necessarily involves cutting into the body. This definition includes all procedures
defined by Method (attribute) with Surgical action (qualifier value).
SNOMED CT classifies concepts as surgical procedures if their methods are surgical actions based on the action
hierarchy. The surgical action hierarchy distinguishes surgical from non-surgical actions based on the definition
above. Note the Or in the sentence; actions that do not involve cutting or incision, but do involve the intentional
non-transient alteration of anatomy, are still surgical.

Operation
In SNOMED CT, operation is synonymous with surgical procedure.

Surgical procedures are not defined simply as procedures done by a surgeon (despite some dictionary definitions).
Surgeons can perform many non-surgical actions and surgical procedures need not necessarily be performed by a
surgeon, i.e. if a non-surgeon performs a surgical procedure, it is still a surgical procedure.

Medical procedure

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The use of the term medical procedure is deprecated, i.e. not recommended, because it lacks
reproducible meaning. It might be defined as a procedure done by a physician, but even that is
deprecated, because it is provider-specific.

Surgical procedure (operation) vs. non-surgical action

As mentioned above, the definition of surgical procedure includes intentional non-transient alteration of structures
of the body and/or necessarily involves cutting into the body. Non-surgical actions do not significantly or non-
transiently alter anatomy and do not necessarily involve cutting or incision.
For example,
Fine needle biopsy (procedure) or brush biopsy (procedure)
Phlebotomy, a synonym for venipuncture for blood test (procedure)
Aspiration (procedure)
Closed reduction of dislocation (procedure)
Closed procedures
The general pattern <open, closed> <procedure> is accepted
When a procedure is specified as closed, the closed procedure should be fully described, e.g. fine needle
biopsy, endoscopic, etc.

Under revision
48635004 | Fine needle biopsy (procedure) | (http://snomed.info/id/48635004) could be viewed as a kind of c
entesis, but the former is non-surgical and the latter is surgical. Sampling - action (qualifier value), in
general, is not necessarily a surgical action. If sampling involves the surgical removal of part of
something, then Surgical biopsy (procedure) should be the action.

Surgical repair
The definition of surgical repair is restoring, to the extent possible, the anatomical structure, using a surgical action.
Repair is an objective or intended accomplishment, not a means (e.g. suturing, transplanting, etc.) nor a need (e.g.
normal functioning, cosmetic appearance, pain relief, etc.).
Surgery that restores structure is usually intended to restore function and appearance. Restoring function, however,
is not necessary for a procedure to be considered a repair. It is also possible for surgery to restore function, without
restoring structure (e.g. surgery to attach a prosthetic limb after amputation). This type of surgery would not be
strictly categorized as a repair.
The Method attribute is used to model both the objective of a procedure and the means used to accomplish it. If a
procedure requires both a repair action and another type of action, then two relationship groups should be used.

Fistula
Closure action is a kind of repair action. All fistula closures use the closure action and are auto-classified as kinds of
repair procedures.
For example,
79433000 | Closure of colon fistula (procedure) | (http://snomed.info/id/79433000) has Method (attribute),
Closure - action (qualifier value) with a parent, Repair of colon (procedure)

Plastic repair
Surgery that accomplishes a repair (a structural restoration) often use the suffix -plasty. The term plastic repair is
also used. In order to avoid redundancy, the following terms are used:
Prosthetic repair, using external (non-body) materials

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Plastic repair, reshaping the body

-plasty
The suffix -plasty is widely used in concepts that apply to prosthetic repairs (e.g. total hip arthroplasty). So
-plasty may refer to any general repair (prosthetic, plastic, or other), and not just plastic repairs.

Revision
A revision procedure is not a subtype of the original procedure.
Revision procedure concepts should be in the 118635009 | Revision (procedure) | (http://snomed.info/id/118635009)
sub-hierarchy.
For example, 171839006 | Re-release of carpal tunnel (procedure) | (http://snomed.info/id/171839006)is modeled as
follows:

Bilateral procedures
The naming pattern is as follows:
FSN: X procedure of bilateral X (procedure)
PT: Bilateral X procedure
SYN: X p rocedure of both Xs
Other synonyms may be added if requested, e.g. left and right X
For example, 732212008 | Amputation of bilateral lower limbs (procedure) | (http://snomed.info/id/732212008)
FSN: Amputation of bilateral lower limbs (procedure)
PT: Bilateral lower limb amputation
SYN: Amputation of bilateral lower limbs
SYN: Amputation of both lower limbs
The concept is modeled as follows:

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Regime/therapy
A regime/therapy is a is a set, sequence, or group of procedures, a subtype of procedure. As a subtype of procedure,
they have the same attributes and use the same model as procedures in general. Regime/therapies are either:
Repeated multiple times, over an extended period of time
For example,
716872004 | Antineoplastic chemotherapy regimen (regime/therapy) | (http://snomed.info/id/716872004), This
regime/therapy might include individual instances of administration of chemotherapy agents; the instances
are at separate times, over a predetermined or planned period of time.
229586001 | Rest, ice, compression and elevation treatment program (regime/therapy) | (http://snomed.info/id
/229586001), This regime/therapy refers to repeated rest, ice, compression and elevation (RICE) for an
indefinite period of time.
Focused on a single purpose, but do not have any single sub-procedure as a necessary part.
For example,
385695003 | Cast care (regime/therapy) | (http://snomed.info/id/385695003), The sub-procedures are all done for
the purpose of properly monitoring and maintaining an orthopedic cast, but the sub-procedures may vary
from one cast, patient, or healthcare setting to the next. Sub-procedures may include inspecting the cast,
checking the skin, reinforcing padding, or etc. There is not a single sub-procedure as a necessary part,
although the purpose of the sub-procedures is to take care of a cast.
It is possible to have a regime/therapy as an instance of care. An instance of cast care could be the specific
care for Mr. Smith's cast on the morning of April 23rd, consisting of the set of procedures: examining the cast;
examining his arm; asking about his symptoms; and cleaning the skin.

Has focus
Regime/therapy may be the value for the Has focus (attribute).
For example,
385978009 | Cardiac rehabilitation assessment (procedure) | (http://snomed.info/id/385978009) with
Has focus, cardiac rehabilitation (regime/therapy)

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Endoscopy vs. endoscopic procedure

Endoscopic procedures are distinguished from endoscopy procedures. The distinction depends on the Action
(qualifier value) of the Method (attribute).
In an endoscopy, the Method is Inspection - action (qualifier value). For these procedures, Endoscope, device
(physical object) is the value for Using device (attribute).
For example,
427595003 | Capsule endoscopy (procedure) | (http://snomed.info/id/427595003) has the Relationship group
Using device, Endoscope, device (physical object)
Procedure site, Direct, Gastrointestinal tract structure (body structure)
Method, Inspection - action (qualifier value)
In an endoscopic procedure, the Method (attribute) has some other action. It is accomplished by gaining access to
the procedure site via an endoscope. For these procedures Endoscope device (physical object) is the value for Using
Access Device (attribute). This specifies that the endoscope is used to access the site.
For example,
53767003 | Endoscopic biopsy (procedure) | (http://snomed.info/id/53767003) has the Relationship group
Using access device, Endoscope, device (physical object)
Method, Biopsy, action (qualifier value)

Centesis
Centesis may be defined as the act of puncturing a body cavity or space with a hollow needle and drawing out fluid.
Each centesis procedure involves both a puncture action and a needle aspiration action. It is correct to have two
relationship groups for centesis procedures.
One group has a Method, puncture action and a Procedure site - Direct, the structure being punctured.
For example,
91602002 | Thoracentesis (procedure) | (http://snomed.info/id/91602002) has Procedure site - Direct, Pleural
membrane structure (body structure)
The second group has a Method, aspiration action and a Procedure site - Indirect, space being aspirated.
For example,
91602002 | Thoracentesis (procedure) | (http://snomed.info/id/91602002) has Procedure site - Indirect, Pleural
cavity structure (body structure)

Inactivation
The value centesis - action was inactivated, since it had two actions with different direct and indirect
objects.

Transplantation and grafting

Transplantation includes procedures that are not grafting

Transplantation

Content in this area is under review and subject to change.

The term transplantation should, in general, be reserved for the transplantation of whole organs or body parts (e.g.,
liver transplant, finger transplant, hair transplant, or etc.).

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Grafting Although the use of terminology may vary across specialties, in general, grafting is
where tissue is completely separated from its source of origin or donor without its own blood
supply, then fixed or attached to a recipient site. The recipient site provides the vascularity.
Fixation or attachment, for example, is of tissue involves skin, bone, cartilage, or fat, rather than whole organs. The
term can also be used for fixation or attachment of some synthetic materials (e.g., a bioengineered skin graft is a
manufactured skin graft grown in the laboratory from the patient's own cells, or from other allogeneic or
xenogeneic sources, and/or synthetic materials, for example, silicone graft, or combined sources).
For example,
Graft of skin
A skin graft is a section of skin, of variable size, thickness and origin.
A skin graft is completely detached from its original site and moved to cover the area to be repaired
without the benefit of any blood supply.
For example,
783285007 | Full thickness graft of skin to skin of neck (procedure) | (http://snomed.info/id/783285007)
Proximal primitive Is a attribute value of 71388002 Procedure (procedure).
One relationship group:
260686004 | Method (attribute) | (http://snomed.info/id/260686004) = 129407005 | Grafting - action
(qualifier value) | (http://snomed.info/id/129407005)
405813007 | Procedure site - Direct (attribute) | (http://snomed.info/id/405813007) = 43081002 | Skin
structure of neck (body structure) | (http://snomed.info/id/43081002)
363701004 | Direct substance (attribute) | (http://snomed.info/id/363701004) = 782792007 | Full
thickness graft of skin (substance) | (http://snomed.info/id/782792007)
Values for direct substance should be from the 420934007 | Graft of skin (substance) | (
http://snomed.info/id/420934007) hierarchy that includes the origin of the material in the
description and a text definition.

Skin flaps are under review and not included here.

Imaging guidance (see also Clinical imaging procedure naming conventions)

Imaging guidance can be modeled using the attribute Has Intent. The concept 429892002 | Guidance intent
(qualifier value) | (http://snomed.info/id/429892002), a child of 363675004 | Intents (nature of procedure values)
(qualifier value) | (http://snomed.info/id/363675004), is the value for Has Intent for imaging guided procedures.
For example,
432666003 | Biopsy of brain using computed tomography guidance (procedure) | (http://snomed.info/id
/432666003) has two relationship groups, the second one below with Has Intent,

Method: Biopsy - action (qualifier value)

Procedure Site - Direct: Brain structure (body structure)
Procedure Site - Direct: Brain structure (body structure)
Method: Computed tomography imaging - action (qualifier value)
Has Intent: Guidance intent (qualifier value)

Biopsy of brain using computed tomography guidance

432666003 | Biopsy of brain using computed tomography guidance (procedure) | (http://snomed.info/id
/432666003) is subsumed by 702707005 | Biopsy of head (procedure) | (http://snomed.info/id/702707005) and
by 34227000 | Computerized axial tomography of brain (procedure) | (http://snomed.info/id/34227000).

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Fluoroscopic guidance
Y using fluoroscopic guidance (procedure) is a subtype of fluoroscopy (procedure).
For example,
710291004 | Endoscopy using fluoroscopic guidance (procedure) | (http://snomed.info/id/710291004) with the
following relationship groups,
Using device: Endoscopic device (physical object)
Method: Inspection - action (qualifier value)
Method: Fluoroscopic imaging - action (qualifier value)
Has intent: Guidance intent (qualifier value)

Excision, incision, biopsy

Excision, incision, and biopsy may be difficult to interpret. They are organized according to the following general
structure.

Excision
Organ excision. Any excisional act involving the organ; usually (organ)-ectomy, or similar, is a synonym. Organ
excision, itself, does not specify whether it is complete or partial, nor does it specify what is excised.
For example,
23968004 | Excision of colon (procedure) | (http://snomed.info/id/23968004) or one of the synonyms, Colectomy

Complete or total excision

Concepts may include complete or total to indicate complete removal or excision of the organ.
For example,
63016009 | Total resection of urinary bladder (procedure) | (http://snomed.info/id/63016009) with the synonyms
Complete cystectomy, Total excision of bladder, and etc

Partial excision
Concepts may include partial to indicate removal or excision of part of the organ. Specifying partial excision does
not differentiate between a partial excision of or from the organ.
For example,
708929007 | Laparoscopic partial excision of kidney using robotic assistance (procedure) | (http://snomed.info/id
/708929007) or one of the synonyms, Partial nephrectomy, laparoscopic with robot assistance

Lesion or tissue
Concepts may indicate removal of a lesion or tissue; excision of a lesion or tissue from an organ may be complete
or partial.
For example,
72106008 | Excision of lesion of liver (procedure) | (http://snomed.info/id/72106008)
69031006 | Excision of breast tissue (procedure) | (http://snomed.info/id/69031006)

Lesion modeling

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The word lesion can be used to refer to both structural and functional abnormalities. If a procedure (or
disorder) refers to a lesion in a way that makes it clear that it is a generic term for a structural
abnormality, then the correct modeling approach is to use Procedure morphology (attribute) for
procedures or [Associated morphology (attribute), Morphologically abnormal structure (morphologic
abnormality) for disorders].

Excision(al) biopsy
Excisional biopsy of entire organ (organ structure)
For example,
447412005 | Excisional biopsy of lymph node of neck (procedure) | (http://snomed.info/id/447412005)
Excisional biopsy of organ generally means that tissue or a lesion or suspected lesion is necessarily entirely excised,
not the entire organ. It is a partial excision of (from) the organ. This is true even when small polyps are removed.
For example,
116237003 | Excisional biopsy of lesion of rectum by transanal approach (procedure) | (http://snomed.info/id
/116237003)

Incision
Organ incision. Any incisional act involving the organ; usually (organ)-otomy, or similar, is a synonym
For example,
45558009 | Incision of lung (procedure) | (http://snomed.info/id/45558009) or the synonym, pneumonotomy

Incision
Any incision procedure that does not necessarily involve division (as opposed to ordinarily does not
involve division) remains primitive without an available negation operator.

Incisional biopsy
Incisional biopsy of organ; incisional biopsy of lesion of organ; usually with open approach. Incisional biopsy of
[organ] necessarily implies incision and removal of a lesion, and is by definition a partial excision, since the site is the
organ, and an excision is done, but the entire lesion is not necessarily removed.
For example,
237378001 | Incisional biopsy of breast (procedure) | (http://snomed.info/id/237378001)

Biopsy
A biopsy may not be an excision.
For example,
445713002 | Brush biopsy of endocervix (procedure) | (http://snomed.info/id/445713002)
48426002 | Fine needle biopsy of kidney (procedure) | (http://snomed.info/id/48426002)

Modeling biopsy
Biopsies, like other removal procedures, may have two direct objects, the morphology and the site. It is
permissable to use Procedure site - Direct for biopsies, even if subtypes might have a direct object that is
a morphology.

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Division, lysis, transection, bisection

Division and lysis

Division action is a subtype of Incision - action (qualifier value). This does not mean that all procedures, that include
the word division, should necessarily be modeled with Method, Division - action (qualifier value); like those where
the division is accomplished using blunt dissection, not incision.
For example,
Division of adhesion concepts, like 173269002 | Division of adhesions of lip (procedure) | (http://snomed.info/id
/173269002), should be modeled the same as lysis of adhesion concepts, like 45602008 | Lysis of adhesions of
peritoneum (procedure) | (http://snomed.info/id/45602008)
Both use dissection - action. Adhesions are broken down by blunt dissection, often without incising them. This does
not exclude procedures that may also involve division by incision.
The preferred name of division of adhesions concepts can be changed to lysis of adhesions for consistency. The use
of lysis of adhesions also helps with correct modeling and avoidance of interpreting divisions as necessarily being
kinds of incision.

Transection and bisection

Transection is defined as a division across the longitudinal axis of a structure by cutting. Bisection is defined as
division into two parts by cutting. Transection - action (qualifier value) is a subtype of Bisection - action (qualifier
value), which is a subtype of Division- action (qualifier value) and Incision - action (qualifier value).
For example,
53176004 | Transection of muscle of eye (procedure) | (http://snomed.info/id/53176004)
60158005 | Bilateral bisection of ovary (procedure) | (http://snomed.info/id/60158005)

Skeletal system
Since the skeletal system includes bones and cartilage, it is possible to have a procedure on the skeletal system, i.e.
on cartilage, that is not a procedure on bone.
For example,
77825002 | Division of cartilage of wrist (procedure) | (http://snomed.info/id/77825002) is a procedure on the
skeletal system (procedure)

Skeletal system subdivision

SNOMED CT considers the skeletal system subdivision part of the entire bone (system). This may change
if there are procedures on cartilaginous skeleton that involve skeletal system subdivisions.

Osteotomy
Osteotomy is defined as cutting into or through a bone; there are 3 meanings in SNOMED CT:
Cutting into a bone, regardless of whether the bone is divided (incision, general meaning). Model using
Method, Incision - action (qualifier value), and Procedure site - Direct (attribute), bone structure (or subtypes).
For example,
118483001 | Incision of rib (procedure) | (http://snomed.info/id/118483001)
Cutting through a bone and dividing it (division by cutting). Model using Method, Division - action (qualifier
value), and Procedure site - Direct (attribute), bone structure (or subtypes).
For example,
447867002 | Division of ulna (procedure) | (http://snomed.info/id/447867002)

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Cutting into a bone without cutting through it and therefore without dividing it (incision without division).
This is unnecessary. Procedures that do not explicitly involve division are modeled simply as Incision.

Inactivated
Osteotomy - action (qualifier value)
Incision of bone without division as a synonym for Incision of bone

Reduction and fixation of fractures

Reduction and fixation has two actions by two different means; open reduction of a fracture and insertion of an
orthopedic fixation device. This provides an opportunity for general concept inclusion axioms (GCIs) in order to fully
represent the meanings, without heavy postcoordination modeling. Open reduction of a fracture necessarily
involves open manipulation of the fracture and internal fixation of a fracture necessarily involves the insertion of an
orthopedic internal fixation device.
For example,
74011006 | Open reduction of fracture of tibia and fibula with internal fixation (procedure) | (http://snomed.info
/id/74011006)

Immunization and vaccination

Immunization may be active (introduction of a vaccine) or passive (introduction of immunoglobulin/antibodies ). A
vaccine is a substance that can induce active immunity. Vaccination, by definition, is the introduction of a vaccine,
and is, therefore, synonymous with active immunization. Some descriptions include the word vaccination, where it
is clear that vaccination is intended. Other descriptions have preferred terms with the word vaccination, and
synonyms with the word immunization, to include both active and passive immunization.
For example,
38598009 | Measles-mumps-rubella vaccination (procedure) | (http://snomed.info/id/38598009) has vaccination
in all descriptions
86198006 | Influenza vaccination (procedure) | (http://snomed.info/id/86198006) has the synonym, influenza
immunization

Encounter
An encounter is defined as an in-person meeting between a patient and a healthcare provider for the purpose of the
provision of healthcare services to the patient. An encounter is a kind of procedure.
For example,
185349003 | Encounter for check up (procedure) | (http://snomed.info/id/185349003)
An indirect encounter is not actually an encounter, since there is no face-to-face meeting. Therefore encounter and
indirect encounter are siblings in the procedure hierarchy.
For example,
11797002 | Telephone call by physician to patient or for consultation (procedure) | (http://snomed.info/id
/11797002)

Qualifier Value*

Changes cannot be made to the Qualifier Value hierarchy without permission from the Head of
Terminology.

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Definition Examples

One of several possible values for an 7771000 | Left (qualifier value) | (http://snomed.info/id/7771000)
attribute used to define concepts
260389003 | No reaction (qualifier value) | (http://snomed.info/id
/260389003)

The 362981000 | Qualifier value (qualifier value) | (http://snomed.info/id/362981000) hierarchy contains concepts used
as the target value of an attribute in a d efining relationship.
The range of values for a particular attribute is provided in the specific concept model of the domain. For further
information on the range of values for a specific domain, please refer to the MRCM Project
18639004 | Left kidney structure (body structure) | (http://snomed.info/id/18639004) has Left (qualifier value) for
the attribute Laterality

Number (qualifier value) hierarchy

Concepts that describe numeric values have been added as descendants of 260299005 | Number (qualifier value) | (
http://snomed.info/id/260299005). While the FSN and PT for these concepts use numeric characters, the concepts
represent descriptions of a number and are not actually numeric values. To reinforce this, a synonym with the
textual description of the number is created for each concept.
For example,
|Zero point two| is the synonym for 732349004 | 0.2 (qualifier value) | (http://snomed.info/id/732349004)

True numeric values

Textual descriptions of numbers provide a path to representing true numeric values, should that become
an option.

Concepts representing numbers

FSN X (qualifier value)

Trailing zeros are not allowed (e.g. 10, not 10.0)
Preceding zeros are required (e.g. 0.5, not .5)
For example,
25 (qualifier value)
37.5 (qualifier value)
125 (qualifier value)

PT X
Trailing zeros are not allowed (e.g. 10, not 10.0)
Preceding zeros are required (e.g. 0.5, not .5)
For example,
25
37.5
125

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Concepts representing numbers

SYN A synonym representing the concept as a textual description is required

Synonyms are not case sensitive. No commas or other punctuation is allowed. An exception is
the hyphen
For example,
Twenty-five
Thirty-seven point five
One hundred and twenty-five

Unit of presentation (unit of presentation) hierarchy

The 732935002 | Unit of presentation (unit of presentation) | (http://snomed.info/id/732935002) hierarchy is used to
support harmonization between SNOMED CT's Drug Concept Model and the International Organization for
Standardization's Identification of Medicinal Products ( IDMP) standards for product strength.

Unit dose
The Unit dose (qualifier value) is unacceptable for representing unit of presentation.

Concepts representing Unit of Presentation

FSN X (unit of presentation)

For example,
Actuation (unit of presentation)
Capsule (unit of presentation)
Suppository (unit of presentation)
Tablet (unit of presentation)

PT X
For example,
Actuation
Capsule
Suppository
Tablet

SYN Synonyms are not allowed

Disposition (disposition) hierarchy

The 726711005 | Disposition (disposition) | (http://snomed.info/id/726711005) hierarchy is required to support the
remodeling of the 105590001 | Substance (substance) | (http://snomed.info/id/105590001) hierarchy. These concepts
are used as the attribute values for the 726542003 | Has disposition (attribute) | (http://snomed.info/id/726542003). The
(disposition) semantic tag is used to differentiate concepts in this hierarchy from similar concepts in other
hierarchies.

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Concepts representing Disposition

FSN X (disposition)
For example,
Coagulation factor inhibitor (disposition)
Acute phase reactant (disposition)
Human immunodeficiency virus fusion inhibitor (disposition)

PT X
For example,
Coagulation factor inhibitor
Acute phase reactant
HIV fusion inhibitor

Modeling
Techniques, as qualifier values, should include the word technique in their FSNs.
For example,
702658000 | Microbial culture technique (qualifier value) | (http://snomed.info/id/702658000)

International System of Units - unit of mass (qualifier value) hierarchy

The 258681007 | International System of Units unit of mass (qualifier value) | (http://snomed.info/id/258681007)
hierarchy contains concepts representing metric units of mass.

Concepts representing Unit of Mass

FSN X metric unit of mass

Lower case with case sensitivity, ci

PT X metric unit of mass

Lower case with case sensitivity, CS
SNOMED CT exception: abbreviated without the expanded form

SYN X metric unit of mass

Lower case with case sensitivity, ci

International System of Units - derived unit of volume (qualifier value) hierarchy

The 282115005 | International System of Units-derived unit of volume (qualifier value) | (http://snomed.info/id
/282115005) hierarchy contains concepts representing metric units of volume.

Concepts representing Derived Unit of Volume

FSN X metric unit of volume

Lower case with case sensitivity, ci

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Concepts representing Derived Unit of Volume

PT X metric unit of mass

Lower case with case sensitivity CS
SNOMED CT exception: abbreviated without the expanded form
For example,
dL
mL
L

SYN Lower case with case sensitivity ci

For example,
deciliter
milliliter
liter

Pharmaceutical dose form (dose form) hierarchy

The 736542009 | Pharmaceutical dose form (dose form) | (http://snomed.info/id/736542009)* hierarchy contains
concepts support the drug model. Please see the Drugs Project Confluence page, Pharmaceutical dose form
Hierarchy - Editorial Guidelines.

Other Qualifier Value Subhierarchies that Support the Drug Model

See the separate guidelines for the following qualifier value subhierarchies that support the drug model at the Drugs
Project Confluence page, Supporting hierarchies.
736478001 | Basic dose form (basic dose form) | (http://snomed.info/id/736478001)*
736665006 | Dose form administration method (administration method) | (http://snomed.info/id/736665006)
736479009 | Dose form intended site (intended site) | (http://snomed.info/id/736479009)
736480007 | Dose form release characteristic (release characteristic) | (http://snomed.info/id/736480007)
736477006 | Dose form transformation (transformation) | (http://snomed.info/id/736477006)
736471007 | State of matter (state of matter) | (http://snomed.info/id/736471007)
105904009 | Type of drug preparation (qualifier value) | (http://snomed.info/id/105904009)
*For these concept model domains that support the drug model, see the attribute and range tables at the
Pharmaceutical/Biologic Product Attributes Summary page.

Record Artifact*

Definition Examples

Clinical documents, or parts 422813005 | Document section (record artifact) | (http://snomed.info/id

thereof /422813005)

416575001 | Perioperative record (record artifact) | (http://snomed.info/id

/416575001)

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A record artifact is an entity that is created by a person or persons for the purpose of providing other people with
information about events or states of affairs.
In general, a record is virtual, that is, it is independent of its particular physical instantiation/s. It consists of
information elements (usually words, phrases and sentences, but also numbers, graphs, and other information
elements).
Record artifacts need not be complete reports or records. They can be parts of a larger Record artifact.
For example,
A 184225006 | Computer record of patient (record artifact) | (http://snomed.info/id/184225006) is a Record
artifact that also may contain other Record artifacts in the form of individual documents or reports, e.g.
726738003 | Cytology report (record artifact) | (http://snomed.info/id/726738003). These may, in turn, contain
more finely granular Record artifacts, such as sections, and even section headers e.g. 422813005 | Document
section (record artifact) | (http://snomed.info/id/422813005).

Situation with Explicit Context

Definition Examples

Concepts that include context information; a 407565004 | Angiotensin II receptor antagonist

subtype of the situation to which it applies, with not tolerated (situation) | (http://snomed.info/id
an attribute associating it with the relevant clinical /407565004)
finding or procedure
417886001 | Treatment adjusted per protocol
(situation) | (http://snomed.info/id/417886001)

Variable meanings according to context

Depending on context, concepts can be used in many different ways with various meanings.
A disorder concept can represent:
Possible diagnosis or part of a differential diagnosis
Diagnosis applied to a family member or some other contact person
Diagnosis explicitly excluded
D iagnosis, now known to be incorrect, but which was the basis for a particular course of treatment
Absent feature of a related disorder
Diagnosis that the patient believes or fears they have
A procedure concept can represent:
Requested, recommended or planned procedure
Procedure for which consent has been given or withheld
Procedure that is contraindicated
Procedure that has been canceled or postponed
Procedure for which follow up is now being arranged
Procedure which caused a complication
A symptom concept can represent:
Confirmed absence of a symptom
Symptom deduced and reported by a third party as a witness of a clinical event
Inability or failure to obtain information about a symptom
Symptom which the patient is advised to respond to in a particular manner
A finding concept can represent:

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Absence of a finding
Inability or failure to check for a finding
Finding which, if present, is to trigger a particular change in clinical management
Finding which is the goal or target of a treatment
A product concept can represent:
Allergy or other contraindication to a product
Assertion that a product caused a particular side effect
Various therapeutic activities of a product
Instructions given to a patient for use of a non-prescription medication
Clinical authorization of a prescription
Issuing of a prescription for a course of treatment
Supply (dispensing) of a specified quantity of a product
Administration of a single dose of a product
Change of a product dosage
Discontinuation of a product
Specialist's recommendation to use a particular product, if certain circumstances apply

Situation with Explicit Context Attributes Summary

When authoring in this domain, these are the approved attributes and allowable ranges. They are from the Human
Readable Concept Model (HRCM). HRCM 2020-01-31

Domain Information for 243796009 | Situation with explicit context (situation) | (http://snomed.info/id/243796009)

Domain Constraint << 243796009 | Situation with explicit context (situation) | (http://snomed.info/id
/243796009)

Parent Domain -

Proximal Primitive << 243796009 | Situation with explicit context (situation) | (http://snomed.info/id
Constraint /243796009)

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 243796009 | Situation with explicit context (situation) | (http://snomed.info
/id/243796009)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

408732007 | Subject relationship 1 0..* 0..1 << 125676002 | Person (person) | (

context (attribute) | ( http://snomed.info/id/125676002)
http://snomed.info/id/408732007)

1 0..* 0..1

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408731000 | Temporal context << 410510008 | Temporal context

(attribute) | (http://snomed.info/id value (qualifier value) | (http://snomed.
/408731000) info/id/410510008)

HRCM 2020-01-31

Author View of Attributes and Ranges for 413350009 | Finding with explicit context (situation) | (http://snomed.info
/id/413350009)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

246090004 | Associated finding 1 0..* 0..1 << 404684003 | Clinical finding

(attribute) | (http://snomed.info/id (finding) | (http://snomed.info/id
/246090004) /404684003) OR
<< 272379006 | Event (event) | (
http://snomed.info/id/272379006)

408729009 | Finding context 1 0..* 0..1 << 410514004 | Finding context value
(attribute) | (http://snomed.info/id (qualifier value) | (http://snomed.info/id
/408729009) /410514004)

408732007 | Subject relationship 1 0..* 0..1 << 125676002 | Person (person) | (

context (attribute) | ( http://snomed.info/id/125676002)
http://snomed.info/id/408732007)

408731000 | Temporal context 1 0..* 0..1 << 410510008 | Temporal context

(attribute) | (http://snomed.info/id value (qualifier value) | (http://snomed.
/408731000) info/id/410510008)

HRCM 2020-01-31

Author View of Attributes and Ranges for 129125009 | Procedure with explicit context (situation) | (http://snomed.
info/id/129125009)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

363589002 | Associated 1 0..* 0..1 << 71388002 | Procedure (procedure)

procedure (attribute) | ( | (http://snomed.info/id/71388002)
http://snomed.info/id/363589002)

408730004 | Procedure context 1 0..* 0..1 << 288532009 | Context values for
(attribute) | (http://snomed.info/id actions (qualifier value) | (
/408730004) http://snomed.info/id/288532009)

408732007 | Subject relationship 1 0..* 0..1 << 125676002 | Person (person) | (

context (attribute) | ( http://snomed.info/id/125676002)
http://snomed.info/id/408732007)

408731000 | Temporal context 1 0..* 0..1 << 410510008 | Temporal context

(attribute) | (http://snomed.info/id value (qualifier value) | (http://snomed.
/408731000) info/id/410510008)

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Situation with Explicit Context Defining Attributes

Context values for Actions

Context values for Actions are under Review.
See the proposed qualifier values for the International Release @ EDITPANEL-15 (https://jira.
ihtsdotools.org/browse/EDITPANEL-15).

Specifically link to document @ Context values for actions (qualifier value); Proposed allowed
qualifier values within the International Release (https://docs.google.com/document/d
/1Rc9c0QyVK6aXHSEui8I5-Ea6HFYavZOiC3DNq1nTd2s/edit?usp=sharing).

The following defining attributes correspond to the Situation with Explicit Context Attributes Summary table.
Associated finding and Finding context are used with Findings with Explicit Context.

Associated finding
This attribute links concepts in the Situation with explicit context hierarchy to their related Clinical finding or Event.
It specifies the Clinical finding or Event concept whose context is being modified.
When Associated finding is used in post-coordinated expressions, its range is broader than when used in pre-
coordinated content. Associated finding should not reference concepts that already have precoordinated context.
For example,
443999008 | Risk of exposure to communicable disease (situation) | (http://snomed.info/id/443999008) with
Associated finding, Exposure to communicable disease (event)
For example, to create the concept, History of thyroid disease in father,
Subject relationship context (attribute) with the value, father (person)
Associated finding (attribute), with the value, Disorder of thyroid gland (disorder)
Incorrect example,
Using Family history with explicit context (situation),
Subject relationship context (attribute) with the value, father (person)
Associated finding with value, Family history: Thyroid disorder (situation)

Finding context
This attribute represents a situation in which a Clinical finding or Event is known or unknown. If known, whether it
is present, absent, or uncertain (possible). It also represents that the finding is not actual, but anticipated or possible
in the future.
For example,
161922009 | No cough (situation) | (http://snomed.info/id/161922009) with Associated finding, Cough (finding)
and Finding context, Known absent (qualifier value)
Subject relationship context and Temporal context are used with Situations, Findings, and Procedures with Explicit
Context.

Subject relationship context

This attribute is used to specify the subject of the Clinical finding or Procedure being recorded, in relation to the
subject of the record.
For example,
161077003 | Father smokes (situation) | (http://snomed.info/id/161077003) with Associated finding, Smoker
(finding) and Subject relationship context, Father of subject (person)

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Temporal context
This attribute indicates the time of the procedure or finding. It may be actual, i.e occurred in the present, in the past,
at a specified time; or in the future, i.e. it is planned or expected. The most general value is simply Current or past
(actual), meaning that the concept was actual (not planned or expected), but not specifying anything further about
the time. The word specified in the Temporal context| means that there is a date or time stamp associated with the
concept in the record. The date and/or time is a point and/or interval, that applies to the concept.
For example,
161550001 | History of hematuria (situation) | (http://snomed.info/id/161550001) with Associated finding, Blood in
urine (finding) and Temporal context, In the past (qualifier value)
Associated procedure and Procedure context are used with Procedures with Explicit Context.

Associated procedure
This attribute links concepts in the Situation with explicit context hierarchy to concepts in the Procedure hierarchy
for which there is additional context.
For example,
183976008 | Operative procedure planned (situation) | (http://snomed.info/id/183976008) with Associated
procedure, Surgical procedure (procedure)

Procedure context
This attribute indicates the degree of completion, or status, of a Procedure, as well as its possible future states, prior
to it being initiated or completed.
For example,
183976008 | Operative procedure planned (situation) | (http://snomed.info/id/183976008) with Procedure context,
Planned (qualifier value)

Situation with Explicit Context Modeling

SNOMED CT contains concepts that include context information and some that are regarded as context-free. A
concept includes context information if the name of the concept explicitly represents information that might
otherwise be represented by another less context-rich concept in a particular place within an electronic health
record or EHR.
In SNOMED CT, context describes the effects of embedding a concept in a clinical situation, i.e. when it is used in an
EHR.
For example,
When the concept 22298006 | Myocardial infarction (disorder) | (http://snomed.info/id/22298006) is used in an
EHR it takes on a specific contextualized meaning. The meaning might be an assertion, by the person
entering the information, that on a given date, the patient was diagnosed with a myocardial infarction. Or, it
may be used to document a complication of smoking, a protocol for chest pain, a medication
contraindication, a part of a patient's medical history, a possible diagnosis justifying a diagnostic test, a
diagnosis excluded by a diagnostic test, a patient's family history, or etc.
The concept for breast cancer, 254837009 | Malignant neoplasm of breast (disorder) | (http://snomed.info/id
/254837009), might be used to indicate a a current diagnosis of breast cancer, family history of breast cancer,
or a past history of breast cancer. Each of these three meanings differs in regard to the context in which
breast cancer is described.
Current diagnosis of breast cancer indicates that the breast cancer is present now, and in this patient.
Family history of breast cancer refers to breast cancer occurring in a family member of a patient.
Past history of breast cancer indicates that the breast cancer occurred in the patient, at some time in
the past, and it is not necessarily present now.

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Not only are the differences significant relative to a patient's health record, but they are also important to
population-based data retrieval, e.g it is incorrect to retrieve those who have a family history of breast cancer when
searching for patients with a diagnosis of breast cancer.

Default context
When a SNOMED CT concept appears in an EHR without any explicitly stated context, that concept is considered to
have a default context. When a concept is entered into an EHR, the information in the health record structure or its
information model, can override the default context.
The default context for a Clinical finding concept implies that the finding is present (vs. being absent), that it applies
to the subject of the record (the patient), and that it is current (or at a specified time in the past, linked to the
concept).
The default context for a Procedure concept implies that the procedure was completed, that it was performed on
the subject of the record (the patient), and that it was done at the present time (or at a specified time in the past,
linked to the concept).

Explicit context
Concepts in the Situation hierarchy (given the appropriate record structure) have explicit context and represent
Clinical findings and Procedures that:
Have not yet occurred
For example,
165137000 | Endoscopy arranged (situation) | (http://snomed.info/id/165137000)
Refer to someone other than the patient
For example,
160303001 | Family history: Diabetes mellitus (situation) | (http://snomed.info/id/160303001)
395083002 | Discussed with next of kin (situation) | (http://snomed.info/id/395083002)
Have occurred at some time prior to the time of the current entry in the record
For example,
161514008 | History of aortic aneurysm (situation) | (http://snomed.info/id/161514008)

Attributes
These attributes are used to represent Clinical finding and Procedure in the Situation hierarchy.

Clinical Finding Procedure

Attributes Associated finding Associated procedure

Finding context Procedure context

Subject relationship context Subject relationship context

Temporal context Temporal context

Expressing context
Context typically alters the meaning of a concept, i.e. the resulting concept is no longer a subtype of the original
concept.
Precoordinated expression. Clinical context is specified in the description and entered into a field in a patient's EHR.
For example,

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The precoordinated expression 266897007 | Family history: Myocardial infarction (situation) | (http://snomed.
info/id/266897007) might be put directly in a blank field in a patient's EHR. A family history of myocardial
infarction is not a subtype of myocardial infarction, so family history modifies the context.
The precoordinated expression 54355006 | Intracranial injury, without skull fracture (disorder) | (http://snomed.
info/id/54355006) might be put directly in a blank field in a patient's EHR. The disorder Intracranial injury,
without skull fracture is not a subtype of skull fracture, so without modifies the context.
Postcoordinated expression. Clinical context is specified by combining concepts.
For example,
281666001 | Family history of disorder (situation) | (http://snomed.info/id/281666001), combined with 246090004
| Associated finding (attribute) | (http://snomed.info/id/246090004) = 22298006 | Myocardial infarction (disorder)
| (http://snomed.info/id/22298006). These two concepts indicate a family history of myocardial infarction.
Concept or expression in an EHR field. A concept is placed in a field with a predefined meaning in an electronic
health record. The meaning is conveyed by the context in which it is recorded.
For example,
Hip replacement planned might be represented as 397956004 | Prosthetic arthroplasty of the hip (procedure)
| (http://snomed.info/id/397956004) within a section of a patient's EHR called Planned actions. A planned hip
replacement is not a kind of hip replacement, so the Planned actions record section modifies the context
2004005 | Normal blood pressure (finding) | (http://snomed.info/id/2004005) might be placed in a field labeled as
Goal in a patient's EHR. A goal of normal blood pressure is not a kind of Normal blood pressure (finding), so
the Goal field in the EHR modifies context

Concepts in medical records

When a user places a concept from SNOMED CT in a patient's EHR, it transforms the concept from a
theoretical representation of a clinical notion to an actual instance of the concept.
For example,
If the concept 192644005 | Meningococcal meningitis (disorder) | (http://snomed.info/id/192644005) is
entered in a patient's EHR, it usually indicates that the patient has had an instance of this disease.
Similarly the entry of 38102005 | Cholecystectomy (procedure) | (http://snomed.info/id/38102005)
would imply that the patient has undergone this procedure.
The placement of a concept in an EHR field may:
Affect the quality of the meaning, but not the instance. The placement of 194828000 | Angina
(disorder) | (http://snomed.info/id/194828000) in a field labeled Current problems, Past medical history,
or History of indicates that an instance of angina has occurred in the patient. The specific field
affects the quality of the meaning, but not the instance. The adopted context is compatible with
the default context.
Critically affect the meaning and the instance. The placement of 49049000 | Parkinson's disease
(disorder) | (http://snomed.info/id/49049000) in a Family history field or 41339005 | Coronary
angioplasty (procedure) | (http://snomed.info/id/41339005) in a Planned procedures field does not
indicate that an instance of the disorder or the procedure has occurred in the patient. The adopted
context is incompatible with the default context (In these circumstances, the electronic health
application programmer needs to identify the appropriate context values from a authoritative list
and link them to the concepts placed in the fields to substitute for their default contexts).
When a Situation with explicit context concept is used in an EHR, it should contain all of the context
attributes and applicable values in order to guarantee accurate meaning if that concept (plus context) is
subsequently transferred to another record environment.

Elaboration: changing concept meaning

Elaboration in SNOMED CT refers to any addition to or change of the meaning of a concept that may be brought
about when it is embedded in a clinical situation. Embedding a concept in a clinical situation may elaborate the
semantic interpretation of a concept in one of the following ways:

1.

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1. Subtype qualification
2. Axis modification
3. Affirmation or Negation
4. Combination

Subtype qualification
Subtype qualification is elaboration that results in a concept that is a subtype of the original unelaborated focus
concept. A focus concept is the part of a SNOMED CT expression that represents a clinical finding, observation,
event, or procedure. It may be given context by a surrounding context wrapper and may be made more specific by
a refinement.
For example,
A past history of replacement of the left hip may be represented by a SNOMED CT expression in which the
Focus concept, hip replacement is refined by laterality, left and enclosed in a context wrapper representing
past history.
A subtype qualification refines the meaning of a concept.
For example,
71620000 | Fracture of femur (disorder) | (http://snomed.info/id/71620000) may be elaborated by indicating
whether the fracture is open or closed or whether it is the left or right femur that is fractured. A patient with
an open fracture of the neck of the left femur has a type of fracture of the femur. Refining the morphology,
site, and laterality act as subtype qualifications.
708038006 | Acute exacerbation of asthma (disorder) | (http://snomed.info/id/708038006) may be elaborated by
adding severity. A patient with a severe exacerbation of asthma has a type of asthma exacerbation . Severity
acts as a subtype qualification.
236886002 | Hysterectomy (procedure) | (http://snomed.info/id/236886002) may be elaborated by specifying a
priority and a surgical approach. A patient who had a routine vaginal hysterectomy had a type of
hysterectomy; priority, i.e. routine, and approach, i.e. vaginal, Priority and approach are subtype qualifications.

Subtype qualification
Subtype qualification has also been considered a qualifier (e.g. ENV136060, GEHR, CTV3) or a secondary
status term (e.g. NHS Context of Care). In SNOMED CT, subtype expresses more clearly the distinctive
property of a qualifier. This is helpful because the meaning of modify and qualify are synonymous in
many dictionaries and some International Organization of Standardization (ISO) authorities.

Axis modification
The attributes used to define situation concepts permit explicit (rather than default) representation of various
contexts. These attributes can change the meaning of a Clinical finding or Procedure concept in a way that changes
the hierarchy (or axis) of the concept from Clinical finding or Procedure to Situation with explicit context. The
resulting modified meaning is not a subtype of the original meaning of the concept, and therefore the axis-
modifying attributes are not used to qualify the concept, but instead are used to qualify a Situation concept.
For example,
The concept 22298006 | Myocardial infarction (disorder) | (http://snomed.info/id/22298006) may be elaborated
by including it in a clinical record specifying family history. A record of a family history of myocardial
infarction does not imply that the patient has had any type of myocardial infarction. Therefore, family history
changes the focus from the default context to a specified context.
The concept 52734007 | Total replacement of hip (procedure) | (http://snomed.info/id/52734007) may be
elaborated by stating that the procedure is planned for some future date. A record of planned total hip
replacement does not imply that the patient has actually had a total hip replacement, i.e. it is not the default
context for a procedure.

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The concept 167272007 | Urine protein test not done (situation) | (http://snomed.info/id/167272007) uses the
context-modifying attribute Procedure context (attribute) and a value of Not done (qualifier value). This
concept is not a subtype of 167271000 | Urine protein test (procedure) | (http://snomed.info/id/167271000),
because its axis (hierarchy) is modified. Note that |<Procedure> not done| is no longer allowed. See the list
disallowed naming patterns at Pre-coordination Naming Patterns JIRA Project.

Axis modification
Axis modification i s not the same as affirmation (present) or negation (not present) of a concept, where
the essential characteristics of the concept are unchanged.

Affirmation and Negation

Depending on perspective, affirmation and negation may simply be viewed as the inversion of meaning of an
unelaborated concept that represents a Clinical finding. A concept may be stated in the negative in a clinical
situation (e.g. meningism not present). This creates the potential for a concept to represent two meanings, one of
which is the inverse of the other. However, the effects of negation on interpretation are far-reaching and distinct
from other elaborations.
Negation, like axis modification, results in a concept that is not a subtype of the unelaborated concept. However,
negation explicitly rules out the unelaborated concept.
For example,
Family history of myocardial infarction does not imply that a patient had a myocardial infarction.
No headache implies that patient has headache is untrue. A negative statement may expand further in the
opposite direction of a positive statement. If headache is a subtype of pain then patient has headache implies
patient has pain. However, patient has no headache does not imply patient has no pain. Conversely, patient
has headache does not imply patient has occipital headache, but patient has no headache implies patient
does not have occipital headache.
A concept may be stated to be possible in a clinical situation. Statements that explicitly indicate uncertainty can be
considered in two possible ways:
Somewhere between affirmation and negation
As a type of elaboration

Combination
Two or more concepts may be embedded in a clinical situation in a way that links them together. Linkages may
include:
Simple combination of concepts
Combination of a concept that is present and another that is absent

Context shift
Once a concept has context-shifted and become context-dependent, it should not be used in an expression, that
once again shifts context. In other words, when one context attribute is given an axis modifying value, the other
context attributes are fixed.
For example,
The model for 430679000 | Family history of diabetes mellitus type 2 (situation) | (http://snomed.info/id
/430679000) is IS A situation-with-explicit-context with,

Subject relationship context, Person in family of subject (person)

Associated finding, Diabetes mellitus type 2 (disorder)
Finding context, Known present (qualifier value)
Temporal context, Current or past (actual) (qualifier value)

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Even though the Family part of the concept results in an explicit axis shift of the Subject relationship context only,
SNOMED CT requires default values for Finding context and Temporal context, rather than allowing them to be
unspecified.
To negate a concept with Finding Context, Known Present (qualifier value), Finding Context becomes Known Absent
(qualifier value).
For example,
The concept 160273004 | No family history: Hypertension (situation) | (http://snomed.info/id/160273004) negates
160357008 | Family history: Hypertension (situation) | (http://snomed.info/id/160357008) by changing the value
of Finding Context to Known Absent with Temporal Context, All times past (qualifier value). It is IS A Situation-
with-explicit-context,
Temporal context, All times past (qualifier value)
Associated finding, Hypertensive disorder, systemic arterial (disorder)
Finding context, Known absent (qualifier value)
Subject Relationship Context, Person in family of subject (person)

Context attributes
When a Situation with explicit context concept is used in a electronic health application, it should contain
all of the context attributes and applicable values in order to guarantee accurate meaning if that concept
(plus context) is subsequently transferred to another record environment.

Modeling procedure context

Acceptable precoordination naming pattern
Procedure refused
For example,
FSN and PT: <procedure> refused (situation)
Synonym: <procedure> declined (situation) (optional)
413123006 | Blood pressure procedure refused (situation) | (http://snomed.info/id/413123006)
There is legacy content that does not follow this modeling.
Unacceptable precoordination naming patterns
The following precoordination naming patterns are no longer accepted for addition to the International
Edition, although some legacy content with these patterns is still present:
Procedure offered
Procedure not offered
Procedure done
Procedure not done
Note that the 385658003 | Done (qualifier value) | (http://snomed.info/id/385658003) (a descendent of
410523001 | Post-starting action status (qualifier value) | (http://snomed.info/id/410523001)) remains in use
as the target value of the 408730004 | Procedure context (attribute) | (http://snomed.info/id/408730004) in
History of <procedure> concepts.

Modeling: No known allergy

The pattern is:
716186003 | No known allergy (situation) | (http://snomed.info/id/716186003)
FSN: No known allergy (situation)

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PT: No known allergy

SYN: NKA - No known allergy
No known X allergy (situation)
For example, 428197003 | No known insect allergy (situation) | (http://snomed.info/id/428197003)
FSN: No known insect allergy (situation)
PT: No known insect allergy

SNOMED Model Component*

Definition Types

Concepts and attributes necessary to organize and structure

1. 900000000000442005 | Core metadata
SNOMED terminology and its derivatives
concept (core metadata concept) | (
http://snomed.info/id/900000000000442005)

2. 900000000000454005 | Foundation
metadata concept (foundation metadata
concept) | (http://snomed.info/id
/900000000000454005)

3. 106237007 | Linkage concept (linkage

concept) | (http://snomed.info/id/106237007)
4. 370136006 | Namespace concept
(namespace concept) | (http://snomed.info
/id/370136006)

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SNOMED Model component module (metadata)

Core metadata concept

Subtypes of 900000000000442005 | Core metadata concept (core metadata concept) | (http://snomed.info/id
/900000000000442005) provide structural information required to support International Release data. This supporting
information includes sets of enumerated values that apply to attributes of concepts, descriptions, and relationships.

Foundation metadata concept

Subtypes of the 900000000000454005 | Foundation metadata concept (foundation metadata concept) | (
http://snomed.info/id/900000000000454005) provide supporting metadata and structural information for derivative
release structures including Reference Sets.

Linkage concept
A 106237007 | Linkage concept (linkage concept) | (http://snomed.info/id/106237007) links two or more concepts to
express compositional meanings. All concept codes that can be used as a Relationship Type are included under
Linkage concept. The Concept Model attributes are approved for use.
Linkage concept is a subclass of SNOMED CT model component. The Linkage concept hierarchy has the sub-
hierarchies:
Attribute (attribute)
Link assertion (link assertion)

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Linkage concept attributes

Concepts in the Linkage concept sub-hierarchy are used to construct relationships between two SNOMED CT
concepts, i.e. they indicate the relationship type between those concepts. Some attributes (relationship types) can
be used to logically define a concept (defining attributes).

Namespace concept
370136006 | Namespace concept (namespace concept) | (http://snomed.info/id/370136006) is a subtype of SNOMED CT
model component. Each of its subtype concepts has an integer term which is an assigned Extension namespace
identifier.

For more information

New namespace concepts are requested via Freshdesk. An internal author adds new IDs as received. It is
also necessary to change the Module ID per the following:

For further details search for Change or Add to SNOMED CT on the IHTSDO website at: http://www.
snomed.org/snomed-ct/learn-more.

Social Context*

Definition Examples

Social conditions and circumstances 413465009 | Afro-Caribbean (ethnic group) | (http://snomed.

related to healthcare info/id/413465009)

Subtypes include: ethnic group, lifestyle, 116060000 | Eating habit (life style) | (http://snomed.info/id
occupation, person, racial group, religion /116060000)
/philosophy, social concept
24413000 | Carpenter, general (occupation) | (http://snomed.
info/id/24413000)

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Definition Examples

133932002 | Caregiver (person) | (http://snomed.info/id

/133932002)

415794004 | Unknown racial group (racial group) | (

http://snomed.info/id/415794004)

61154002 | Hinduism (religion/philosophy) | (http://snomed.info

/id/61154002)

22575004 | Middle class economic status (social concept) | (

http://snomed.info/id/22575004)

Social Context
These concepts represent social aspects affecting patient health and treatment.

Special Concept*

Definition Examples

Inactive and navigational (support locating 363664003 | Erroneous concept (inactive concept) | (
concepts in hierarchies) concepts http://snomed.info/id/363664003)

394899003 | Oral administration of treatment

(navigational concept) | (http://snomed.info/id/394899003)

Inactive concepts
Inactive concepts are no longer active in the terminology. Subclass concepts indicate the reason a concept is
inactive.
Navigational concepts

NO LONGER ACCEPTED IN SNOMED CT CORE

The concepts in navigational hierarchies are used for structured data entry. They can order data by priority or
another convention (e.g. cranial nerve order or topics related to diabetes ).
Navigational concepts exist only to support navigation. They:
Are not suitable for recording or aggregating information
Are direct subtypes of the concept 363743006 | Navigational concept (navigational concept) | (http://snomed.
info/id/363743006)

Have no other supertype or subtype relationships

Are linked to other concepts only by navigational links
For more information on navigational concepts, click here (see page 54).

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Specimen

Definition Examples

Entities that are obtained (usually from patients) for 384744003 | Lymph node from sentinel lymph
examination or analysis node dissection and axillary dissection
(specimen) | (http://snomed.info/id/384744003)
122880004 | Urine specimen obtained by clean
catch procedure (specimen) | (http://snomed.info/id
/122880004)

Specimen concepts can be defined by attributes which specify the:

Normal or abnormal body structure from which they are obtained
Procedure used to collect the specimen
Source from which it was collected
Substance of which it is comprised

Specimen Attributes Summary

When authoring in this domain, these are the approved attributes and allowable ranges. They are from the Human
Readable Concept Model (HRCM). HRCM 2020-01-31

Domain Information for 123038009 | Specimen (specimen) | (http://snomed.info/id/123038009)

Domain Constraint << 123038009 | Specimen (specimen) | (http://snomed.info/id/123038009)

Parent Domain -

Proximal Primitive << 123038009 | Specimen (specimen) | (http://snomed.info/id/123038009)

Constraint

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 123038009 | Specimen (specimen) | (http://snomed.info/id/123038009)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

118171006 | Specimen 1 0..* 0..1 << 71388002 | Procedure (procedure) |

procedure (attribute) | ( (http://snomed.info/id/71388002)
http://snomed.info/id/118171006)

118170007 | Specimen source 1 0..* 0..1 << 125676002 | Person (person) | (

identity (attribute) | ( http://snomed.info/id/125676002) OR
http://snomed.info/id/118170007) << 35359004 | Family (social concept)
| (http://snomed.info/id/35359004) OR
<< 133928008 | Community (social
concept) | (http://snomed.info/id

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/133928008) OR
<< 276339004 | Environment
(environment) | (http://snomed.info/id
/276339004) OR
<< 260787004 | Physical object
(physical object) | (http://snomed.info/id
/260787004)

118168003 | Specimen source 1 0..* 0..1 << 49755003 | Morphologically

morphology (attribute) | ( abnormal structure (morphologic
http://snomed.info/id/118168003) abnormality) | (http://snomed.info/id
/49755003)

118169006 | Specimen source 1 0..* 0..1 << 442083009 | Anatomical or

topography (attribute) | ( acquired body structure (body
http://snomed.info/id/118169006) structure) | (http://snomed.info/id
/442083009)

370133003 | Specimen 1 0..* 0..1 << 105590001 | Substance (substance)

substance (attribute) | ( | (http://snomed.info/id/105590001)
http://snomed.info/id/370133003)

Specimen Defining Attributes

The following defining attributes correspond to the Specimen Attributes Summary table.

Specimen source identity

Specimen source identity specifies the type of individual, group, or physical location from which a specimen is
collected.
For example,
419695002 | Environmental swab (specimen) | (http://snomed.info/id/419695002) has the Specimen source
identity, Environment (environment)

Specimen source morphology

Specimen source morphology specifies the morphologic abnormality from which a specimen is obtained.
For example,
447407009 | Specimen from necrotic tissue (specimen) | (http://snomed.info/id/447407009) has the Specimen
source morphology, Necrosis (morphologic abnormality)

Specimen source topography

Specimen source topography specifies the body site from which a specimen is obtained.
For example,
16209771000119101 | Specimen from left lower lobe of lung obtained by bronchoalveolar lavage procedure
(specimen) | (http://snomed.info/id/16209771000119101) has the Specimen source topography, Segment of lower
lobe of left lung (body structure)

Specimen procedure
Specimen procedure identifies the procedure by which a specimen is obtained.
For example,

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384744003 | Lymph node from sentinel lymph node dissection and axillary dissection (specimen) | (
http://snomed.info/id/384744003) has the Specimen procedure, Dissection procedure (procedure)

Specimen substance
Specimen substance specifies the type of substance of which a specimen is comprised.
For example,
110897001 | Bone marrow cytological material (specimen) | (http://snomed.info/id/110897001) has the Specimen
substance, Bone marrow fluid (substance)

Staging and Scales*

Definition Examples

This hierarchy contains concepts which are named, Assessment

authoritative, and internationally relevant staging or
273472005 | Functional status index (assessment
grading systems used to either make a judgment
scale) | (http://snomed.info/id/273472005)
about the patient, e.g. cognition, or, evaluate a
patient to determine the phase, or progression of a Staging
disease.
254294008 | Tumor-node-metastasis (TNM) head
and neck tumor staging (tumor staging) | (
http://snomed.info/id/254294008)

Some diseases are represented using a staging and/or grading system to signify the severity, extent, or rate of
growth of a disease. For example, chronic kidney disease is represented with five stages determined by level of
kidney function.

Assessment scale requests

Generally, requests to add the most recent version of an assessment scale are accepted.
Updated versions of existing content are also accepted.
Older versions may be added if justification is appropriate. Older versions may also remain as active concepts
due to the need to retain history on the use of specific instruments.

Modeling
Concepts of the type |Assessment using X assessment scale| are modeled with a proximal primitive parent of
445536008 | Assessment using assessment scale (procedure) | (http://snomed.info/id/445536008) or one of its subtypes,
as appropriate.
For example,
445719003 | Assessment using visual analog pain scale (procedure) | (http://snomed.info/id/445719003) has a
parent of 445536008 | Assessment using assessment scale (procedure) | (http://snomed.info/id/445536008)
(See also Why is Content Rejected page, Proprietary Names for information about use of Questionnaire and Scale
names)

Substance

Definition Examples

Active chemical constituents of allergens, agents, 116272000 | Dietary fiber (substance) | (http://snomed.
substances, chemicals, drugs, and materials (not info/id/116272000)
Pharmaceutical/Biological Products)

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Definition Examples

52454007 | Albumin (substance) | (http://snomed.info

/id/52454007)

Concepts from the Substance hierarchy are used to represent general substances and chemical constituents of
Pharmaceutical / biologic products, which are in a separate hierarchy.

Editorial guidelines in development

Editorial guidelines are in development for the Substance hierarchy. There will be iterative
documentation spanning multiple international release cycles. Comments will also be solicited from the
Project Group. The guidelines will be relocated to the Editorial Guide after they are tested and stable. The
current guideline draft is located on the Substance Project Confluence space @ Reference
Documentation - Substances.

Substance concept and causative agent

When creating a new concept that includes a substance in the FSN, where no exact matching substance concept
exists, then a new substance concept with an FSN, and a PT matching the FSN, should be created (the terms in the
new concept should match the terms used in the FSN and PT of the substance concept selected as the causative
agent).
For example,
418689008 | Allergy to grass pollen (disorder) | (http://snomed.info/id/418689008) modeled with causative agent,
256277009 | Grass pollen (substance) | (http://snomed.info/id/256277009)

Substance Attribute Summary

When authoring in this domain, this is the approved attribute and allowable range. It is from the Human Readable
Concept Model (HRCM). HRCM 2020-01-31

Domain Information for 105590001 | Substance (substance) | (http://snomed.info/id/105590001)

Domain Constraint << 105590001 | Substance (substance) | (http://snomed.info/id/105590001)

Parent Domain -

Proximal Primitive << 105590001 | Substance (substance) | (http://snomed.info/id/105590001)

Constraint

Proximal Primitive -
Refinement

HRCM 2020-01-31

Author View of Attributes and Ranges for 105590001 | Substance (substance) | (http://snomed.info/id/105590001)

Attribute Grouped Cardinality In Group Range Constraint

Cardinality

0 0..* 0..0

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726542003 | Has disposition << 726711005 | Disposition

(attribute) | (http://snomed.info/id (disposition) | (http://snomed.info/id
/726542003) /726711005)

738774007 | Is modification of 0 0..* 0..0 << 105590001 | Substance

(attribute) | (http://snomed.info/id (substance) | (http://snomed.info/id
/738774007) /105590001)

Substance Defining Attributes

Editorial guidelines are in development for the Substance hierarchy. The current Substance editorial
guidelines draft is located on the Substance Project Confluence space at: Substance Project.
Documentation will be developed in iterations that span multiple International Release cycles, with
comments to be solicited from the Project Group intermittently. Editorial guidelines will be relocated to
the Editorial Guide after they are tested and deemed to be stable.

The following defining attributes corresponds to the Substance Attribute Summary table.

Has disposition
This attribute enables the creation of an association between a substance concept and a disposition (A disposition is
defined as a behavior that a substance will exhibit or participate in, given the appropriate context).

Is modification of
This attribute indicates that the concept is a structural modification of another concept.

Substance Naming Conventions

Editorial guidelines are in development for the Substance hierarchy. The current Substance editorial
guidelines draft is located on the Substance Project Confluence space at: Substance Project.
Documentation will be developed in iterations that span multiple International Release cycles, with
comments to be solicited from the Project Group intermittently. Editorial guidelines will be relocated to
the Editorial Guide after they are tested and deemed to be stable.

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Appendices
This section provides guidance for terms in fully specified names and synonyms.

Appendix A: SNOMED CT Requirements

Key requirements that drive the design, development, and maintenance of SNOMED CT are as follows. They are
related to:

1. Electronic health applications (most often electronic health records or EHRs)

Support for effective delivery of high quality healthcare to individuals and populations
2. The terminology
3. Implementation and migration
4. The intended user communities
International, multilingual applicability
Supporting particular localities
5. National and strategic priorities

These requirements are interrelated. The design objective is to enable all user communities to realize the potential
benefits. However, the needs of different user communities may vary. To meet the overall objectives, the design
must consider the entire range of needs. The approach must also be scalable, to enable extension to new user
communities.

Medical Vocabularies - J. Cimino

The headings in this section are the requirements identified in Desiderata for Controlled Medical Vocabularies in the
Twenty-First Century by J.J. Cimino published in Methods of Information in Medicine 1998:37:394-403. Following
each, is an explanation of the way in which SNOMED CT meets the requirement.

Content, content, and content

SNOMED CT content must be adequate both in scope and quality and must:
Cover a wide variety of domains and different organizational needs, clinical disciplines, and medical
specialties
Meet the needs of an expanding scope, while retaining quality, with a structured systematic approach

Nonvagueness and nonambiguity

Codes must have one meaning (nonvagueness) and no more than one meaning (nonambiguity). These
characteristics are sometimes called concept orientation, but SNOMED CT deprecates the use of the word concept
to describe codes or their meanings.
A code and its meaning may be expressed by more than one term. The terms vary between languages and dialects.
In any language or dialect there may be several synonymous terms.

Code permanence
Once assigned a meaning, a code must not change its meaning. Refinements, due to changes in the state of
knowledge, may lead to inactivation of codes from SNOMED CT. An inactivated code may be replaced by a new,
more precisely defined code.

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Nonsemantic identifiers
The structure of an identifier (code) should not contain any semantic information about its meaning or
relationships.

Polyhierarchy
SNOMED CT supports multiple hierarchies. A code may have more than one hierarchical parent and various paths
to its root code.

Formal definitions
When possible, the meaning of codes should be formally defined by relationships to other codes.

Reject, not elsewhere classified

Codes with the phrase, not elsewhere classified, are not allowed in SNOMED CT. However, many classifications
contain terms with this phrase. A term with not elsewhere classified includes general variants that are not
specifically represented. The meaning of such a code may change over time. As codes with more specific meanings
are added, this narrows the codes included in the not elsewhere classified codes.

Multiple granularities
Different users will need to express more or less finely granular meanings. SNOMED CT:
Must accommodate a wide range of levels of detail
Must recognize the relationships between meanings at different levels of granularity
Should allow selection of codes that include navigation to other codes with more or less finely grained
meaning
May need to restrict the levels of granularity used in different applications or in different contexts within the
same application

Multiple consistent views

The view of a code's meaning, with multiple hierarchical parents, should not depend on reaching it by following the
hierarchy from a particular parent.

Beyond terminology codes - represent context

The meaning of a code in a patient record may be altered by its context. Standards for patient record architectures
and modeled healthcare communication are changing. The role of SNOMED CT in the context of these structures
should be evaluated and appropriate recommendations made.

Evolve gracefully
Terminologies need to change over time. SNOMED CT should implement these changes in ways that are well-
documented and tracked and that provide a path for systems and users.

Recognize redundancy
The same information can often be coded in different ways. A controlled terminology, that has an adequate scope,
cannot exclude this possibility. Instead it should facilitate recognition of equivalent terms.

Electronic Health Applications

The anticipated benefits of SNOMED CT are derived from use of information to support effective delivery of high
quality healthcare to individuals and populations.

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Individuals

Aide-memoire for clinicians

Clinically relevant information in an electronic health record acts as an aide-memoire for the clinician, enabling
recall of previous interactions.

Structured data entry

Structured data entry enhances the value of an electronic health record in various ways. It may:
Simplify recording of frequently collected data
Ensure that information is collected in a reliable and reproducible way
Help clinicians to think logically about a patient's condition
Clinical applications may combine several data entry methods. Some of the most commonly used methods are as
follows:
Searching a coded terminology for matching terms using words or phrases
Navigating a hierarchical structure to refine or generalize meanings
Using templates or protocols to record structured information; may be based on answers to questions or
values entered on a data entry form
Parsing of natural language to identify and retrospectively code and structure data
Typing, speech recognition, and document scanning

SNOMED CT requirements for data entry

Data entry may require selection from a list. Such lists must be manageable in size and appropriate to the needs of
the user.
A multilingual, multidisciplinary terminology requires mechanisms that limit and/or prioritize access to terms
and codes in ways that are appropriate to:
Languages and dialects
Countries, organizations, disciplines, specialties, and users
Contexts within a record or protocol
To display a code's description in a list that has not been derived from a text search, the term must be
intelligible and appropriate to the user.
When a code is entered in a record it may require structured entry of additional qualifying information.
Qualifying information may be coded.
For example, the code named removal of kidney may require a statement of laterality.
Qualifying information may be numeric.
For example, the code named hemoglobin measurement may enable entry of a numeric value expressed in a
substance concentration.
To meet all the needs for coded structured data entry in a health record, a terminology must have an adequate
scope.
The main body of SNOMED CT covers the required scope.
It may be difficult to meet the needs of some organizations, specialties, and users; they may need
specific terms or codes to meet their own operational requirements. Therefore, SNOMED CT is
structured to allow for additions to meet specific needs.
A clinical terminology requires frequent changes including new codes, terms, and relationships between codes.
Changes may be required due to new:
Health risks

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Health and disease process information

Drugs, investigations, therapies, and procedures

Presentation
The presentation of clinical information may:
Highlight key information and indicate links between items, thus helping clinicians understand patients'
conditions.
Be determined entirely by record structure without regard to the terminological resource (e.g.,may be in
chronological order, by author, or by the type of recorded event).
Be enhanced based on its semantic content (e.g., grouping procedures, investigation results, or observations
relevant to a particular disease process).

Decision support
Interfaces between recorded clinical information and appropriate decision support tools and reference works may
assist the clinician in selecting diagnostic tests, making diagnoses, and choosing treatment. Decision support
requires selective retrieval and processing of information in an individual health record to determine whether the
patient has particular characteristics relevant to the decision support protocol. The algorithms for establishing the
presence of characteristics should include relationships between coded meanings and other aspects of record
structure. Performance is also important, as decision support algorithms are typically run in real-time during data
recording. Decision support algorithms may:
Depend on numeric or other values (and their units) associated with particular observations
Include the context in which information is recorded, e.g., the date of recording and any stated relationships
between individual items of information
Include information such as age, sex, clinical conditions, findings, surgical procedures, medication, and social
/environmental factors, such as occupation
Use codes or identifiers from other terminologies, classifications, or proprietary schemes. Mapping tables are
required to allow applications that use a terminology to interface with these resources

Communication
Effective delivery of high quality healthcare to individuals requires communication between those involved in
providing care. This requires communication within and across teams or organizations.
The primary objective of many clinical communications is to convey information from human to human.
Communications with this purpose should include human-readable text. Relying on text from coded data is not
recommended. Coded data is therefore not relevant to the requirement for human-to-human communication.
A receiving application may process clinical communications. This information may need to be retrieved and
processed to meet terminology requirements. To meet terminology requirements, messages and other means of
electronic communication must permit the communication of SNOMED CT identifiers and associated structures.
Communication specifications, such as those produced by HL7 and CENTC251, define the structures to meet
requirements. The coded information is used in two distinct situations:
Coded elements that must be filled with codes enumerated in the specifications. The codes enumerated in
the specifications generally communicate, mission critical features of the message. Some of the enumerated
codes and the codes in a clinical terminology may have overlapping meanings.
Coded elements that are populated with clinical codes from appropriate coding schemes. The open coded
elements may require the full expressiveness of a terminology. Some of the open coded elements may be
restricted to codes that express particular types of meaning.
For example, HL7 requires that coding schemes meet certain criteria, one of which is the ability to express limited
subsets of codes appropriate to particular elements.
There are two situations in which communication of coded information may be of value for human-to-human
communication. They are where:
The storage capacity or communication bandwidth is restricted. Receiving applications must contain (or have
real-time access to) a table listing the text description associated with each code.

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The translation between the languages of the sender and the recipient is needed. A coded representation of a
meaning may allow the appropriate description in the recipient's language.
Recording a particular code may trigger a communication. And, receipt of a code, may trigger specific processing in
the receiving application.
For example, recording a decision to prescribe a medicine might trigger an electronic prescription sent to the
pharmacy. Receipt of such a prescription might trigger dispensing and stocking activities.

The relationship of a trigger, is an additional characteristic of a code, that may be context dependent.

Patient involvement
Patients may wish to view, and comprehend, their own records. For SNOMED CT to meet this requirement, the
inclusion of patient-friendly terms should be considered. However, this requirement should not take precedence
over accurate professional terminology.
Patients may also be allowed to contribute to their own records, i.e. be users of SNOMED CT.
For example, patients with diabetes may monitor and record their blood glucose levels.

Populations

Identify and monitor health needs

The provision of effective high-quality care to populations requires an understanding of the state of health and
healthcare needs of that population. Information recorded about individual patients must be available for analysis to
determine trends.
It must be possible to analyze data recorded with SNOMED CT.
Population trends are usually monitored at a higher level, using codes that are more general than those used in
individual patient records. This may be accomplished through one or both of the following methods:
Using hierarchical relationships and/or equivalences defined within SNOMED CT.
Mapping SNOMED CT codes to codes in appropriate classifications.
Appropriate analysis of information requires reliable and reproducible queries.
The scope of SNOMED CT must cover the types of information relevant to analysis.
Analysis may require data about multiple clinical characteristics. Queries must account for both the
terminology and the record structure.

Audit quality of service

The requirements for analysis of quality of service are similar to those for analysis of health needs. The main
difference is that the scope of the analysis must be extended to cover consultations, referrals, procedures,
medications, and other interventions.

Support research
The requirements for research are also similar to those for analysis of health needs, however, there is a need to
allow for:
Recording interventions in ways that do not compromise blind and double blind trials.
Adding SNOMED CT content for experimental observations or treatments, which may never require
permanent addition to the terminology.

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Reduce bureaucracy; manage and fund care delivery

The management and funding of healthcare delivery often depends on recording and reporting of particular
information, e.g. bundled or packaged care. Automating this process offers a way of reducing bureaucratic
overhead, i.e. mapping clinical information recorded with SNOMED CT to appropriate forms..
Some information required for management and funding purposes is specifically related to claims for particular
events or services.
For example, funding general practitioners in the NHS is dependent on meeting immunization administration and
cervical cytology screening targets.
The scope of SNOMED CT must be adequate to meet these needs, or must be capable of extension to meet these
needs, without presenting irrelevant terms or coded meanings to those not requiring them.

Enable reporting of external health statistics

Organizations, such as WHO and some government bodies, require specific data related to healthcare statistics.
Organizations should be able to use clinical information recorded with SNOMED CT. When this is not possible, the
clinical information should at least support their manual generation. Using structured data entry allows for direct
mapping to statutory national and international classifications such as ICD, CPT, OPC, and etc.

Identify patients in need of interventions proactively

Population-based preventive care should be offered to specific groups, based on sex, age, medical history and other
factors. Health information applications based on information recorded with SNOMED CT can be used to identify
patients so they can be offered appropriate care.

Implementation and Migration

Electronic health application

A terminological resource is only one part of an electronic health application. Implementation of SNOMED CT
should support applications in meeting user needs, rather than adding a burden to development.
The functions required to implement a terminology can be divided into those that are:
Performed without reference to data stored in a particular application record structure.
Involved in storing, retrieving, or processing application data.
Applications may make use of different aspects of SNOMED CT. Some may require SNOMED CT for a very limited
range of uses for which there may be minimal value. These applications may not require all the functions for a full
implementation or all the concepts and codes in SNOMED CT.
There may be a general benefit in consistency with other more terminology rich applications.

Existing information
A substantial body of clinical information may already be present in an electronic health application. Much of this
information is represented using existing coding schemes, terminologies, and classifications. This information may
be of value to individual patient records or to populations. Similarly, there are many queries and decision support
protocols that contain information based on existing terminologies.
A new terminology should make provisions for the continuing use of information stored in records, queries, and
protocols represented by other terminologies. There are two general approaches to this:
Conversion of legacy data into a form consistent with SNOMED CT.
Allowing legacy and SNOMED CT data to coexist. Legacy codes must be recognizably different from SNOMED
CT codes. In addition, the relationship between codes in SNOMED CT and legacy codes must be recognized
when retrieving data.

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Reliability and reproducibility

Information represented with SNOMED CT codes must be reliable and reproducible. This means:
The meaning of a code should not change over time.
Information should be reproducible independent of the application.
The query of codes should be reliable. This means:
There should be complete recall, including specific, more detailed codes and expressions subsumed by
general codes and expressions in the query.
There should be specificity and precision excluding codes and expressions that are not subsumed by
the codes and expressions in the query.
The effects of the following should be taken into account:
Precoordinated relationships between codes in records or queries.
Postcoordinated qualifications applied to codes or expressions in records or queries.
Relationships between codes and other contextual information implied by the record structure.

User Communities

Language
The terms required by users of a clinical terminology vary according to the local languages and dialects.
When using a terminology, users must see terms in a language and dialect with which they are familiar. The
terms must be clear and unambiguous independent of any hierarchical context or formal definition.
The display of terms must not be confused by inclusion of terms in other languages or dialects.
The terms used in different languages and dialects are not mutually exclusive. A term may be common to
several languages or dialects of a language.
When a code is presented without a specific reference to a term, an appropriate preferred term should be
displayed. A term may be a preferred term in one dialect and a synonym in another.
Some terms differ only in spelling conventions (e.g. color, colour). The same spelling variants may recur in many
different terms.
It may be appropriate to recognize these cases and handle them differently from other term variants.
An individual instantiation of an application may only require access to a single language or dialect. It is
inappropriate to install and maintain all language and dialect variants.
An application may need to support several languages with the ability to switch between languages and dialects in
real-time to meet the needs of users.

Specialty
Some specialties or disciplines prefer to use different terms to describe the same meaning. A particular specialist
may use a precise term, while a generalist may use a different term to describe the same condition.

Use of terms
The following table lists factors affecting term use and examples of each.

Factors affecting term use

Factor Examples

Geographic and seasonal differences Malaria is more common in certain regions

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Factors affecting term use

Hay fever is more common in spring, summer,

and fall

Cultural perceptions of health Acceptance of alternative therapies

Discipline or specialty Obstetricians use fundus to mean fundus of the

uterus; gastroenterologists use the same term to
mean fundus of the stomach
Surgeons record operative procedures relevant
to their specialties

Professional criteria The definition of hypertension may vary based

on professional guidelines

National or organizational requirements, including those for Performance measure results affecting
administrative or funding purposes reimbursement

Topics of special interest to individual clinicians Infectious disease specialist with an interest in
tropical diseases

Organization, country, and user

Particular terms may be specific to an organization. They may not be included in the International Release of
SNOMED CT. Organizations and users must be able to add terms or codes to SNOMED CT, without devaluing the
main body of SNOMED CT.
It may be necessary to combine several subsets and extensions to meet the needs of a country, an organization, or
a specialty. There must be consistent rules for combining subsets and extensions.
The requirements of a particular user may change according to the role they are performing. A single instance of an
application may need to support different requirements of several users.

Summary
A summary of the SNOMED CT requirements is as follows. Additional information may be found throughout this
Guide, as well as in other documents on the SNOMED International website at at: http://www.snomed.org/snomed-
ct/learn-more.

Terminology Structure

Coded meaning The central component is coded meanings

Each code must have a single clear and unambiguous meaning

Identifier Components must have unique identifiers

The internal structure of these identifiers must not imply the meaning or
relationships of a code

Description Represents the association between terms (text strings) and the meanings
that they describe (may be language or dialect dependent)

Preferred Term

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Represents the special association between each code and a preferred

term (used to display the meaning, unless there is an alternative
preference)

The preferred term association is language or dialect dependent

Fully Specified Name Provides each code with a structured fully specified name that
unambiguously describes its meaning
The fully specified name is defined in a reference language (the language
of first use)
Translations of the fully specified name may also be required

Hierarchy Represents hierarchical relationships between coded meanings

The form of representation allows a coded meaning to have multiple
hierarchical parents (supertypes)
It guarantees that any alternative hierarchical view of a coded meaning is
consistent

Relationship Represents non-hierarchical relationships between coded meanings

Content

Scope The scope is adequate to meet the requirements of various countries,

organizations, disciplines, and specialties
The extent to which the content requirements are covered develops over
time
However, the initial release should cover:
The scope of the existing clinical terminologies
All versions of the Read Codes and NHS Clinical Terms
All versions
Other scope requirements identified by the Editorial Board

Updates The content is regularly updated

Granularity Allows coded meanings to be expressed at different levels of granularity

Not Elsewhere Classified Codes with not elsewhere classified or not otherwise specified must be
(NEC); Not Otherwise inactivated and no new ones may be added
Specified (NOS)

Extension Allows extensions to the main body of work

Extensions are distinguishable from components of the main body;
should be traceable to a responsible organization
Allows for distinguishing and tracing the code source or identifier used in
patient records

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Maintenance and Distribution

Distribution Distributed in a format that is readily usable by application developers

This format is fully specified and is not changed from release to release
May be distributed for use with associated software, such as a browser

Persistence The meaning of a code is persistent; It is not changed or deleted by

updates
A code may be marked as inactivated when its meaning is found to be
ambiguous, redundant or otherwise incorrect
Changes to the association between a concept and a code do not change
or delete the description. The description is marked as inactivated, and a
new corrected description is created

History All changes to components are tracked and saved in history files (includes
details about new components and changes to the status of components)
When a component is made inactive, relationships or references indicate
the replacement or equivalent component

Subsets

Concepts Includes a mechanism for representing subsets of concepts appropriate

for a language, dialect, or specialty. It should allow:
Specification of the synonyms, preferred terms, and translated fully
specified names in each language or dialect
Rational combination of languages and modification of language
subsets to meet the needs of organizations or specialties

Codes Includes mechanisms for representing subsets of codes for a country,

organization, discipline, or specialty. The form of representation should
allow:
An indication of the priority, or frequency of use
Rational combinations of subsets to meet the needs of users or
groups of users

Specified Contexts Includes mechanisms for representing subsets of codes and concepts for
particular contexts in a record, decision support protocol, or data entry
field

Combinations Include consistent rules for combining subsets to meet the requirements
of users

Distribution and Installation Subsets are distributed in a format that is readily usable by system
developers. The format is fully specified and does not vary from release to
release. The distribution format allows:

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Subsets

Subsets to be installed separately

Related or interdependent subsets to be selected and installed as
groups
Subsets to be updated with each new release

Configuration It is possible to configure an application to use a particular subset or

combination of subsets; changing configurations does not require
reinstallation

Relationships

Navigating Relationships Includes relationships that allow hierarchical navigation from a

chosen code to a code that represents either a subtype or part of the
chosen code
Supports navigation from a specific code to more general codes that
represent a supertype of that code

Aggregation of Related Codes Includes relationships that allow aggregation of related codes to
enable comprehensive and accurate retrieval from patient records
These relationships, together with appropriate history and cross-
reference tables, enable the aggregation to include inactivated codes
with similar or equivalent meanings

Defining Characteristics Includes formal definitions of codes represented by relationships with

defining characteristics (e.g. the anatomical site of the code named
appendicitis is the vermiform appendix)

Qualifying Characteristics Enables a code recorded in a patient record to be qualified by adding

relevant qualifying characteristics
Each qualifying characteristic is itself a code with a specified
relationship to a qualified code
Specifies possible qualifying characteristics for each code or for a
group of related codes (e.g. an anatomical site could be added to the
code named osteoarthrosis)

Kind-of-Value Enables codes to be qualified by the addition of relevant values

Specifies the types of values that can be added to particular codes (e.
g. a substance concentration value can be added to the code named
hemoglobin concentration)

Additional Characteristics Is able to assert other characteristics of a code that may be time- or
context-dependent (e.g. new medical information may require
updates to some codes)

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Retrieval

Analysis Enables the consistent and reproducible storage of information,

which is subsequently retrieved for analysis; this requires retrieval
that allows the inclusion of subtypes and equivalent codes to be
included. Equivalent codes may include:
Codes represented in another (legacy) coding scheme
Redundant codes that were inactivated
Combinations of general codes and qualifying characteristics
Analysis usually requires retrieval of selected records from a
population of patient records; usually performed in batch

Patient Review Enables the consistent and reproducible storage of information,

which is subsequently retrieved for patient recall for preventive
procedures or review; requirements similar to those for analysis

Decision Support Enables the consistent and reproducible storage of information,

which is subsequently retrieved for decision support
Requirements are broadly similar to those for analysis
Decision support requires retrieval of selected records from an
individual patient record
Requires real-time processing to determine code meaning
equivalence

Presentation Enables the consistent and reproducible storage of information,

which is subsequently retrieved for presentation
Requirements are similar to those for decision support
Must be real-time, but usually involves filtering by broad
categories of code; less precise than for decision support

Searches and Text Parsing

Searches and Text Parsing SNOMED CT facilitates searches for descriptions

A simple keyword index may be generated from the
descriptions and used for more effective searching although
this may not be optimal due to:
Use of abbreviations
Word form variants
Word order variants
Word equivalences and combinations
Locally added mnemonics for frequently used
descriptions
Composite coded meanings that can only be
represented by:

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Searches and Text Parsing

Combinations of a code with one or more

qualifying characteristics
Multiple codes related together by the patient
record structure components
Searches with multiple redundant hits for a single code
When several synonyms of the same code match
the search key
When techniques for word equivalences and
combination are applied and return alternative
descriptions related to the same code for two or
more word equivalences
Searches with multiple redundant hits for a large
number of closely related coded meanings
Search keys matching descriptions associated with a
code with a more general meaning and many of its
more specific hierarchical descendants
A further complication is the application of searches within subsets. This
restricts the range of available concepts or codes; efficiency may depend on
the relationships of keyword indices and subsets

Parsing or Encoding Free Text The use of natural language parsing to encode free-text derived from
typing, scanning, or voice recognition is increasing; the text of
descriptions and associated search indices may assist with this
process

Implementation

Terminology Services Terminology services should be implemented independent of

application data; by individual applications or by terminology servers
accessible by many applications

Advice Application data cannot be specified to the same level of detail as

terminology services. It us dependent on the general functionality of
the application and its record structure
Providing advice early in the SNOMED CT implementation process is
required. This helps with some issues that may not be immediately
apparent to developers

Limited Applications The advice provided should not place onerous requirements on
applications with limited needs for the SNOMED CT terminology
It is inappropriate to have all-or-nothing requirements for SNOMED
CT enabled applications

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Legacy Data and Migration

Code Recognition It should be possible to distinguish a code from an earlier coding

schemes (SNOMED, Read Codes, or NHS Clinical Terms) from the
identifiers used in SNOMED CT

Equivalence It must be possible to relate each code in early coding schemes

(SNOMED, Read Codes, or NHS Clinical Terms) to a code in
SNOMED CT

Query/Protocol Conversion There must be support to convert queries and protocols, based early
coding schemes (SNOMED, Read Codes, or NHS Clinical Terms), to
SNOMED CT compatible forms

Record Conversion It should be possible to convert legacy data, based on early coding
schemes (SNOMED, Read Codes, or NHS Clinical Terms), to
SNOMED CT compatible forms. This is subject to medico-legal
constraints

Migration of Terminology- Projects in the UK NHS, that currently make use of Read Codes or
Dependent Products NHS Clinical Terms, must plan migration to allow future use of
SNOMED CT

Data Structure

Patient Record Architectures SNOMED CT is intended to represent clinical meanings in patient

records
A patient record consists of a series of related statements that
are organized under headings
The statements and headings may contain clinical codes
derived from SNOMED CT
Headings, and other contextual elements, may modify the
meaning of related statements
The relationship between a terminology, such as SNOMED CT, and
a record architecture can be summarized as follows:
SNOMED CT codes and terms may populate different
elements in the record structure
Different SNOMED CT codes may be applicable to
different elements in the record
Some codes may not be appropriate for inclusion in
the record
The meaning of a SNOMED CT code may be modified by its
context within the record structure
SNOMED CT should be evaluated within the context of evolving
standards for patient record architectures. Recommendations based
on the evaluations may include:

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Data Structure

Possible changes to record architectures in order to realize

benefits from SNOMED CT

Changes to SNOMED CT to better fit into record structures

Selecting SNOMED CT codes for use in specific record
structure contexts

Expression Coordination and Some codes may be entered in a precoordinated or a post-

Equivalence coordinated manner

For example, "excision of ovary" might be entered by:

selecting the precoordinated code 83152002 |Oophorectomy

(procedure)|,

or alternatively by selecting the codes for

71388002 |Procedure (procedure)| and adding the qualifying
characteristics:

260686004 |Method (attribute)| = 129304002 |Excision - action (qualifier

value)|
405813007 |Procedure site - Direct (attribute)| = 15497006 |Ovarian
structure (body structure)|
The coded meanings are stored in the forms entered. This may be
using a single precoordinated code, a single post-coordinated
expression, or a set of separate codes that together represent the
clinical meaning.
A retrieval query must therefore search for the precoordinated and
all possible post-coordinated ways of expressing equivalent
meanings. This can be done using the Expression Constraint
Language (http://snomed.org/ecl) and a terminology service that
can compute subsumption between expressions.
These methods for retrieving records based on their clinical
meaning rely on the formal definitions of SNOMED CT concepts
being as complete as possible. Missing defining characteristics may
result in problems with equivalence testing and therefore data
retrieval.

Communication

Clinical Information The ability to communicate clinical information (represented by

SNOMED CT) between applications must be supported
Message specifications and other communication structures must
accommodate SNOMED CT identifiers, and combinations of
identifiers, in order to express postcoordinated coded meaning

Message Specifications Current message specifications (e.g EDIFACT, HL7, and XML) use
plain text files; SNOMED CT identifiers must use plain text so that
they are appropriate for these messages

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Communication

Postcoordinated Expressions Communication of postcoordinated expressions may be possible

using specific qualifier fields in messages. This can also be
accomplished by using syntactic representation of identifier
combinations; these must be consistent with message syntax and
field size limitations

Mapping

Classification Based on recorded codes, mapping tables are used to generate

statistical and administrative data
Automation of the process depends on the nature of the
classification, the richness of the mapping table, and the
functionality of the mapping software

Grouping Mapping tables are used to generate groupings for funding,

administration, and etc
Mapping to a classification, then using the classification codes to
generate groupings, is an alternative method

Communication Specifications Codes are mapped to specific values, in an enumerated list,

associated with a message or communication specification
Recognizing these mappings may prevent double data entry, when
sending or receiving such messages

Reference Works Codes are used to establish links with decisions-support protocols
or other references
Mapping between these codes and reference sources may help to
facilitate their use

Availability

Limited Applications Applications vary in their ability to use terminological components

Special consideration may be necessary for applications that require
only limited use of SNOMED CT

Concepts in Different Languages Translating SNOMED CT into other languages is required

Multiple translations may support communication of clinical
information across language barriers

Patients Patients may be users of SNOMED CT if they record information in

their own medical records
This may require limited licensing of SNOMED CT for populations, in
general

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Appendix B: Concept Models

The SNOMED CT concept model specifies the way in which SNOMED CT concepts are defined using a combination
of formal logic and editorial rules. Concept model rules specify the top level concepts under which concepts are
arranged in the subtype hierarchy and the types of relationships that are permitted between concepts in particular
branches of the hierarchy.
The information that follows is additional/background information about the two concept models. The information
necessary for authoring for the two concept models is in Anatomical Structure Modeling and Disorder Combination
Modeling.

Anatomical Concept Model

The Structure-Entire-Part (SEP) model

SNOMED CT uses a structure-entire-part triple, known as the SEP triple, to represent anatomical structures. The
following Relationships provided a way for the anatomy in CTV3 to be mapped to RT:

The SNOMED CT anatomy hierarchy differentiates classes of entire anatomical entities from classes of
parts of entire anatomical entities.
Entire concept: Denotes a class that is instantiated by entire anatomical entities of some kind: entire heart is
instantiated by all individual hearts.
Entity Part concept: Denotes a class that is instantiated by all anatomical entities that are a proper part of some
entity of a given kind: heart part is instantiated by all entities that are a proper part of some heart, e.g. my mitral
valve, your right ventricle, Joe's sinus node. Heart part is not instantiated by any heart.
Entity Structure concept: Subsumes both the related Entire and Part concepts. Consequently, it denotes a class
which is instantiated by anything that instantiates either the Entire or the Part. For instance, Heart structure is
instantiated by my heart, my mitral valve, your heart, your right ventricle, Joe's sinus node, Joe's heart, etc.

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The code named Liver structure in CTV3 is equivalent to Liver structure in the diagram above. Both the CTV3 code
for Liver structure and the SNOMED RT code for Liver are interpreted to mean Some or all of the liver. Site attributes
(PROCEDURE SITE, FINDING SITE) will usually take the value liver structure rather than entire liver , since typically
the site of a liver disorder or procedure on the liver is not necessarily the entire liver.

Purpose of the Structure concept

Adding the Entity Structure codes is a convenience to assist with the logic-based aggregation of references to the
entity or its parts. The implication of this view is that the E of the SEP triple is the code that should be regarded as
the one that represents the real anatomical entity that is named.
For example, the code for entire liver is the one that should correspond to the code for liver in the Foundational
Model of Anatomy (FMA). The subtype hierarchy for entire liver fits much better with the FMA hierarchies, and
indeed it might be possible to completely reconcile SNOMED’s non-Structure components with FMA anatomy.
A database has been developed that categorizes codes in the physical anatomical entity hierarchy according to their
status as S structure, P Part or E Entire, and provides the corresponding S and P code for each E code. This should
provide some value to implementers. It can help with navigation, coordination with formal ontologies of anatomy,
and selection of codes for postcoordination.

Naming conventions
S concepts are usually named x structure (body structure) or structure of x (body structure). E concepts are usually
named entire x (body structure) or x entire (body structure). P concepts are usually named x part (body structure) or
part of x (body structure).

Plurals
Outside the anatomy section of SNOMED CT, plurals were primarily used as headers, while the individual concept
names were singular. In the anatomy section, we have taken plurals to represent meaningful differences from their
singular counterparts.
For example, Skin structure of all fingers in the FSN would mean more than one finger, while Skin of finger would
not imply more than one.

Conventions for merging concepts from SNOMED RT and Clinical Terms v.3
Where there were two concepts with the same name, the SNOMED RT code was to become the S code, and the
CTV3 code was to become the E code. There are still instances of unrecognized pairing of the RT-CTV3 S-E pair,
where neither codes FSN has been changed according to the naming conventions in this document. When these
unmatched pairs are identified, it is our practice to change the FSNs accordingly, and to make the E code have a
subtype IS-A link to the S code.

S concepts without a corresponding E concept

Some S codes do not currently have a corresponding E code subtype, and there was no policy that required that
such E codes be created during the merger of SNOMED RT and CTV3. However, it is likely that such a policy will be
enforced in the future.

S Structure codes can subsume entities other than E or P

The SEP triple may give the impression that all S codes have exactly two children, one E and one P, with all of the
remaining descendants placed under P. Again, in the past this degree of modeling consistency was not always
followed. Some codes were purposely made subtypes of the S that are not strictly part of the corresponding E.
For example, perirenal tissue is a kidney structure but not a part of the kidney. It is used to define perirenal abscess
so that it is subsumed by renal abscess. While a perirenal abscess is not strictly within the substance of the kidney, it
is still considered a kind of renal abscess, and the S anatomy hierarchy is used to support this inference.
This policy has introduced undesirable variation and arbitrariness into the terminology, and future revisions will seek
to eliminate these variations. Where a code is needed for a site that is really meant to extend to entities that are not
part of any kidney, this will be made clear in the name, e.g. Structure of kidney and perirenal tissue.

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Countable vs non-countable E entities

The E code needs to be interpreted with care when the x name refers to entities that do not have the property of
identity, meaning that they are not countable wholes, or could be interpreted as non-countable. In this
circumstance, the interpretation of E means some portion of the thing being named.
For example, tissue and types of tissue such as fascia, muscle, tendon, bone tissue, connective tissue, skin, mucosa
/mucous membrane, nerve tissue, etc. Muscle, tendon, bone and skin can identify a type of tissue as well as an
individual organ of that type. Bone tissue has no identity, but a particular bone does have identity.
To use skin as the archetypal example, the E code for skin of finger means a portion of the skin of a finger, so all of
its subtypes must also be portions of skin. The S code for skin of finger then has a subtype P which would mean
proper part of a portion of skin of finger. This admits subtypes that are not kinds of skin, but may be parts of skin,
including layers, e.g. epidermis of finger (meaning a portion of epidermis of finger) could be a proper part of a
portion of skin of finger.

Tissues, layers, membranes: portions

We regard the E code for x tissue, x layer to have the meaning portion of X tissue, and therefore regional
subdivisions of tissue types are direct subtypes.
For example, transitional epithelium of urinary tract, as an E kind of code, should be a supertype of transitional
epithelium of urinary bladder. The reason is that (portion of) transitional epithelium of urinary bladder is a kind of
(portion of) transitional epithelium of urinary tract.
We also deal with layers the same way.
For example, we regard serosal layer and serosa tissue as meaning the same thing, since all serosal tissue is
conifigured as a layer, and it can’t be a serosa without being a layer; and their E codes mean portion of serosal layer
or portion of serosal tissue.
As another example, layer of retina would be a supertype of nerve fiber layer of retina, and also a supertype of
retinal epithelium, where retinal epithelium represents a portion of the epithelium of the retina and is therefore a
kind of (portion of) a layer.

Groups
The identity/countability issue extends to a problem differentiating groups of entities from one of the group.
For example, consider x = lymph node group, y = lymph node. In this case, the group should be linked to the
member via an appropriate Relationship (not yet in SNOMED CT), such as has-member. In those cases where y is
always necessarily a member of group x, it could be linked via a member-of Relationship (also not yet in SNOMED
CT).

What does part of mean?

There are several possible ways of interpreting part of. In SNOMED CT, A part of B means that in normal anatomy,
the entire structure A is structurally included in B. Another way of saying it is that A is part of B if there is no part of
A that is not also part of B.
For example, the humerus is not part of the shoulder region, because the distal humerus is part of the humerus, and
the distal humerus is not part of the shoulder region.
We do not use part of for non-anatomical meanings, such as grouping tests together in batteries, nor do we use it
to indicate Relationships that are not strict anatomical inclusion.
Some recent work has begun to differentiate between part of that is reflexive (that is, an entity is in some sense a
part of itself, much the same that a set can be viewed as a subset of itself), versus proper part of, where an entity
cannot be a proper part of itself. For now, we regard part of Relationships as implying strict partonomy.
There is sometimes confusion about parthood as opposed to location.
For example, an embryo is not part of a mother's body, but a kidney is. The anatomy section is composed mainly of
canonical parts; but a few abnormal parts are included to permit them to be used as the location of tumors or
injuries.

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For example, a Meckels diverticulum is a body structure that is part of the small intestine, and it is also a
morphological abnormality. Likewise some stomas and other post-surgical structures are considered part of the
body. A transplanted liver or kidney would be considered part of the body, as a post-surgical structure, even though
the transplanted organ is not genetically identical. Likewise transplanted bone marrow is part of the body.
Non-living implants and devices, and foreign bodies, on the other hand, are considered to be located in the body,
but not part of the body.

Part of relationships
For more information on part of relationships in the anatomy concept model, please see 4. Part of
relationships (under development).

Can the SNOMED CT relationships table be used to construct a part of hierarchy?

The currently distributed part of Relationships need to be much more extensively modeled and quality assured. At
present they are not defining, that is, their Characteristic Type in the relationship file is additional, and, therefore,
they do not affect the classifier behavior. A substantial amount of effort has gone into a draft of the updated part of
Relationships; these will require review and approval before incorporation into the release. This will eventually result
in the SEP triplet structures and part of relations being strictly paralleled. It is a matter of time to implement and
quality assure the changes.

Why are part of relationships not defining?

The SEP structure, combined with the inference mechanism that is used with SNOMED CT, allows us to take
advantage of anatomical Relationships to infer subsumption, IS_A Relationships between disorders, procedures, and
other entities without reference to part of Relationships. The SEP structure also permits us to sufficiently define
anatomical structures without reference to part of Relationships (making them necessarily true, but not among the
necessary and sufficient conditions).
For example, the Structure of left hand can be sufficiently defined as a hand structure with laterality = left. This
definition is sufficient. Converting the part of Relationships to have Characteristic Status = defining will require
significant changes to the current model.

Entities with mass versus purely spatial massless entities

Points, lines, and surfaces can be considered to be massless. The FMA calls these immaterial. It is important to
differentiate the codes/names for these entities from those that are intended to represent entities that have mass. At
present, the concepts under anatomical spatial entity represent massless entities. Massless entities are not
represented using the SEP model. It is conceivable that users may want to reference parts of a surface, and to
enable this we would need to apply the SEP model to anatomical spatial entities, or else adopt defining part of
Relationships.

Attributes used to define body structure concepts

Laterality
This attribute provides information on whether a body structure is left, right, or bilateral. It is applied only to
bilaterally symmetrical body structures which exist on opposite sides of the body.

Unilateral
Unilateral: with the addition of lateralized content in the International Release, the need for unspecified unilateral
concepts is obviated, as well as potentially dangerous if used directly in a patient record. Unilateral concepts will not
be accepted and a review of existing content for potential inactivation is underway.

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Disorder Combinations

Combined disorders and clinical life phases (CLPs)

The model for combined disorders is based on the reimagining of clinical disorders as clinical life phases which
represent a period of a person’s life during which they are experiencing one or more pathological conditions
(pathological structures, dispositions or processes). The subtype relationship in this case is analogous to the subset
relation of set theory in which Y is a subtype of X if all members of Y are wholly included as members of X rather
than Y being more specific than X. In this manner, a combined life phase consisting of CLP a and CLPb will inherit
both CLPa and CLPb as parents as all individuals with the combined CLP of CLPa and CLPb are also individuals with
CLPa and are individuals with CLPb.

Temporal relationships and the meaning of co-occurrence

Relations between two time intervals may be described using a formalism known as Allen’s interval algebra[i] (see
page ). The basic relations (and their converses) between 2 time intervals are illustrated below where a and b are
individual CLPs and relations are represented by small letters and their converses by capital letters. Note the relation
“equals” is its own converse.

Figure 1: Allen's basic relations and converse relations (https://www.ics.uci.edu/~alspaugh/cls/shr/allen.

html#Allen1983-mkti)
We define co-occurrence as the situation in which time interval a (e.g. a CLP) is wholly present during time
interval b (or conversely time interval b is wholly present during time interval a).

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Figure 2: Allen's basic and converse relations compatible with co-occurrence

As it would undoubtedly be difficult to distinguish among these various temporal relations in a clinical setting, we
can represent the relationship between a and b in Allen’s syntax as a(fsdeFSD)b which indicates the disjunction of all
the patterns depicted in figure 2 above.
Thus, in deciding whether CLPa and CLPb are co-occurrent, the question becomes can either life phase persist after
the other has resolved. If the answer is no, then CLPa and CLPb are co-occurrent. As an example, consider the
conjunction of coronary artery embolus and myocardial infarction. Clearly the embolus may resolve after treatment
but the infarcted myocardial tissue will not and thus coronary artery embolus and myocardial infarction are not
considered to be necessarily co-occurrent. On the other hand, consider the conjunction of intestinal obstruction
and volvulus. The intestinal obstruction would no longer exist once the volvulus is reduced and thus volvulus and
intestinal obstruction are necessarily co-occurrent.
In terms of simple co-occurrence, two life phases may be necessarily co-occurrent but clinically related by an
association in which neither condition causes the other. These types of clinical associations often are related by a
common predisposition and therefore simple co-occurrence would be most appropriate for representing overlap
syndromes (e.g. asthma with COPD) as well as to associate two CLPs (CLPa and CLPb) in which after reviewing the
current literature one is still unsure of whether a causal chain exists between CLPa and CLPb. (especially relevant for
genetic mutations and associated phenotypes).

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[i] (see page )Allen, James F. "Maintaining knowledge about temporal intervals". Communications of the ACM 26
(11) pp.832-843, Nov. 1983.

Causality
We consider the notion of causality as a primitive predicate, which is essential for medical reasoning and decision-
making. Whether y follows x incidentally or because it is caused by x is seen as fundamentally different. Causal
relationships between disorders are represented using the due to role. A causal relationship should be considered as
any point in a causal chain between X and Y and for which X is not merely a risk factor for Y and for which X is
temporally separated by Y by an interval where it is reasonable to believe that the association between X and Y is
not just coincidental.

Risk factors vs. cause*

A cause is an event, condition, or characteristic without which the disease would not have occurred.
A risk factor is a surrogate or marker for an underlying cause (e.g. education and income status are risk
factors but not causes of ischemic heart disease
*http://sphweb.bumc.bu.edu/otlt/MPH-Modules/EP/EP713_Causality/EP713_Causality3.html

Figure 3: Example of causal chain for ischemic heart disease adapted from The Global Health Risks Report, WHO
2004
Due to may be thought of as a differentia to distinguish between simple co-occurrence and co-occurrent and
due to. It may be used when co-occurrence or temporally following is uncertain in lieu of additional temporal
patterns such as during and after currently not represented in SNOMED CT.

Causality and co-occurrence

Disorders that are both co-occurrent and causally related are no longer modeled with "co-occurrent and due to."
Only the use of "due to" is appropriate.

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Use of the associated with attribute

In general, 47429007 | Associated with (attribute) | (http://snomed.info/id/47429007) should be avoided due to the
ambiguity which it conveys and the difficulty in applying this role consistently. There is only one situation when
47429007 | Associated with (attribute) | (http://snomed.info/id/47429007) could possibly be considered appropriate*.
General grouping concepts which aggregate more specific associations
For example, 6211002 | Polyarthritis associated with another disorder (disorder) | (http://snomed.info/id/6211002)
subsumes two children
201972000 | Allergic arthritis of multiple sites (disorder) | (http://snomed.info/id/201972000) modeled with
42752001 | Due to (attribute) | (http://snomed.info/id/42752001) of 419076005 | Allergic reaction (disorder) | (
http://snomed.info/id/419076005)

422565003 | Post-infective polyarthritis (disorder) | (http://snomed.info/id/422565003) modeled with 255234002 |

After (attribute) | (http://snomed.info/id/255234002) of 40733004 | Infectious disease (disorder) | (http://snomed.info
/id/40733004)

“Due to” is used when there is a strongly suspected or known causal relationship between the conditions;
otherwise, the clinical conditions should be recorded separately.

For more information see Disorder Combination Modeling.

Appendix C: Principles for Accepting Content in the International Release

The statement of scope for the International Release is that it includes content necessary for international
conformance and interoperability. Content that is within the scope of the International Release is restricted to the
International Release and may not be modified or replaced by an extension, unless explicitly permitted by SNOMED
International. Affirmative answers to the following questions are criteria for inclusion in the International Release:
Is it useful in more than one national healthcare system?
Does it need to be understandable in electronic health applications in more than one national healthcare
system?
Can it be used in electronic health applications beyond a patient's national healthcare system, i.e. if a patient
were to travel or relocate to a different country?

Use of proprietary names and works

This section considers scope as it relates to the incorporation of proprietary names (e.g. names of clinical
forms or tools, and drugs) into SNOMED CT. The section is divided into two sub-sections. The first one
covers SNOMED International itself. The second one covers third parties (e.g. SNOMED International
Affiliates) who implement SNOMED CT in electronic health applications (Note: there is some overlap
between these sections).
Clinical form or tool
In this section, we refer to the owner of a clinical form or tool. This term loosely refers to the person or
organization that owns the intellectual property rights of the form or tool. This may be the individual or
group that originally created the form or tool, the organization that employed the creators, or a
commercial organization to whom the creators assigned their intellectual property rights.

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SNOMED International

Names
Incorporating the name of a clinical form or tool (e.g. the XYZ Test), or the name of the score generated by a form
or tool (e.g. the XYZ Test Score) into SNOMED CT does not require a license from the owner. It is possible that the
owner holds a trademark (which may be registered or unregistered) representing the name or score, but simply
incorporating that word into SNOMED CT does not infringe on the trademark.
This also applies to brand name drugs. SNOMED International does not need to obtain the permission of the
trademark owner simply to include a reference to the brand name drug in SNOMED CT.

Questions
A clinical form or tool, including the wording of the individual questions within the form or tool, is generally a
literary work and qualifies for copyright protection. The copying of all or any substantial part of a literary work,
without a license from the owner, infringes on the copyright.

Answers
Certain questions may have a range of pre-determined answers. This could be as simple as Yes/No or a number
within a specific range, but may also be more substantial (e.g. needs help cutting, spreading butter, etc., or requires
modified diet).
Incorporating very simple answers into SNOMED CT does not require permission. However, incorporating more
substantial text into SNOMED CT generally infringes on the copyright. This usually does not apply to individual
answers, but it almost always applies when entire sets of answers are incorporated.

Scores
The principles that apply to individual answers also apply to the overall score generated by a clinical form or tool.
The incorporation of numbers does not infringe on the copyright. However, when each possible score has an
associated textual description and all possible scores and descriptions are incorporated into SNOMED CT, a license
is required.

Concepts representing questions, answers, or scores

A concept may be introduced into SNOMED CT that represents the text of questions, answers, or scores. For
example, a form may include a question about a person's ability to dress and a range of possible answers. SNOMED
CT may incorporate neither the text of the question nor any of the possible answers, but instead may incorporate a
concept such as ability to dress. Similarly, if the form contains 20 questions, SNOMED CT may want introduce 20
concepts, for XYZTest_Result1, XYZTest_Result2 and so on, to XYZTest_Result20.
The incorporation of a single concept into SNOMED CT, based on a question, answer, or score on a clinical form is
highly unlikely to infringe on the copyright. However, if SNOMED CT systematically introduces a concept for every
single question on a clinical form, it is likely to infringe on the copyright.
These concepts (e.g. ability to dress) may already exist in SNOMED CT, or they may be added in other contexts (This
does not apply to concepts that represent specific questions within a form). This is unlikely to result in a copyright
infringement.

Implementation of SNOMED CT

Names
The use of the name of a clinical form or tool or of a brand name drug will usually not infringe on the copyright.
However, caution should be exercised by implementers who wish to use trademarks in a commercial context, i.e. a
system that enables drugs to be purchased electronically. SNOMED International does not advise implementers on
this matter, but recommends that implementers, who are in any doubt, contact the trademark owner.

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In general, implementers should make no greater use of a trademark than is necessary. For example, displaying a
graphical mark (e.g. a logo) on a screen or in printed material should be avoided.

Questions, answers, and scores

Implementers should manage questions, answers, and scores in the same way as SNOMED International (see
above). When the incorporation of content from a clinical form or tool infringes on the copyright, the system the
reproduces (by display or print) the content also usually infringes. This means that the license to incorporate
content by SNOMED International should also cover the system implementer .

Preexisting terms
As noted above, terms in a clinical form may already exist within SNOMED CT, even though they have not been
copied from the form. This is not copyright infringement by SNOMED International. If, however, a system
implementer chooses to arrange a collection of these pre-existing terms in a way that reproduces all or a substantial
part of a clinical form (e.g. by populating a drop-down box with all of the possible answers to a specific question on
the form), that may infringe on the copyright.

Form structure
A system may reproduce the structure and layout of a clinical form on a screen display or printed output (e.g. to
make the system more accessible to users who are familiar with a paper-based form). This may infringe on the
copyright, unless the structure or layout is very minimal (e.g. a bulleted list). An implementer who wishes to emulate
the look and feel of a clinical form should seek a license from the owner.

Algorithms or logic
System implementers may use the algorithm or logic inherent in a clinical form or tool (e.g. the method by which
an overall score is calculated). For example, a clinical form may instruct the user to perform a mathematical
operation on the individual answers to produce the overall score, and the same operation may be carried out by the
system. The use of the algorithm or logic is an infringement. SNOMED International avoids such use and
encourages system implementers to contact the owner to discuss possible infringement.

Management of non-human content

Non-human content may be included in a request for new content via the SNOMED International Request System
(SIRS) or may be identified in the International Release. Careful consideration is required to differentiate content that
belongs in the International Release versus an extension. The basic principle is that content used in human
medicine should be in the core. Content that is strictly non-human may be managed in an extension.
Examples of non-human content,
Egg-related coelomitis (disorder)
Dehorning (procedure)
Bone structure of wing (body structure)
Types of content that should be in the core include the following:
Diseases and findings. Anything that can occur in both humans and animals should be in the core.
Material entities. Every substance that can cause adverse effects should be in the core (with the
understanding that poisonings and adverse effects in humans may be caused by virtually any substance).
Some material entities may be of interest only in a non-human or veterinary context. These entities may be
added to, or left in, a veterinary extension.
Organisms. Most organisms should be in the core, with some exceptions. There are over 20,000 organism
codes in the Veterinary Extension maintained by the Veterinary Terminology Services Laboratory (VTSL) at
Virginia Tech University. Generally, these are not transferred to the core, except when used in public health or
human medicine or when requested by more than one SNOMED International member country.
Organisms that are not used in human medicine can be added to the Veterinary Extension. It is publicly available to
SNOMED International member countries and to Affiliate Licensees. To access to the Veterinary Extension, see
http://vtsl.vetmed.vet.edu (http://vtsl.vetmed.vet.edu/)|http://vtsl.vetmed.vet.edu/ or contact VTSL at vtsl.e (mailto:vtsl.
[email protected])[email protected] (mailto:[email protected])

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Principles for determining National Extension content

A National Extension includes content outside of the scope of the International Release, but necessary for national
conformance and interoperability. Each member-state determines the application and interpretation of this scope
and whether or not concepts should be added to their extension.
Criteria to determine if concepts should be included in a National Extension include affirmative answers to the
following:
Is the concept outside of the scope of the International Release, but necessary for national conformance and
interoperability?
Is it useful throughout the national healthcare system?
Does it need to be understandable throughout the national healthcare system?
Does it need to be shared in a reproducible manner within the national healthcare system?
If so, then the concept may be eligible for the National Extension.

Appendix D: Historical Notes

This page is no longer updated. Please see summary of changes provided in the linked spreadsheet found
on the Editorial Guide homepage, http://snomed.org/eg.

Added or changed
Domain change for measurement/evaluation attributes. Six attributes were approved for Measurement procedure
only. The domain for these attributes was expanded to Evaluation procedure.
Dose form values. Type of drug preparation (product) and its subtypes were moved to the Qualifier value hierarchy.
Type of drug preparation (qualifier value) better represents these concepts because they are not products.
Finding to Event. A number of concepts moved. The attributes used to define those concepts were retained in the
Clinical finding hierarchy.
Route of Administration. Allows a procedure to be more fully modeled, so that its definition includes the route of
administration of a given substance.
Situation with explicit context (situation). Previously named Context-dependent category.

Summary of historical domain relationships

Domain Historical Relationship

Ambiguous component Possibly equivalent to

Component moved elsewhere Moved to

Duplicate component Same as

Erroneous component Replaced by

Was a

Limited component Was a

Outdated component Replaced by

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Was a

Pending move Moved to

Non-conformance to editorial policy None required

No longer valid
Access for Endoscopic route of access. Information that was previously captured by Access, Endoscopic approach-
access (qualifier value) is adequately captured with Using Access Device, Endoscope, device (physical object).
Has Definitional Manifestation. Not being used in an understandable, reproducable and useful way.
Inactivated
Approach. Use for non-surgical procedures not reproducible.
Episodicity no longer modeled in active content. Was used not to specify the first episode of a disorder for a patient
but rather, the first time a patient presented to the healthcare provider for a disorder.
Onset and Course. Could not be used reproducibly. Onset easily confused with Course.
Using (replaced with Using Device). Allowed values that included descendants of Physical force (physical force)
which are not actually devices. The Device attributes clarify the inconsistency that existed over when to use Using
vs. Access Instrument vs Access, particularly for Endoscopic procedure.
Other
Surgical and related procedure domains in Clinical Terms Version 3. Generated from the OPCS4-based Chapter 7 of
Read Version 2 by the addition of new concepts during the Clinical Terms Project (CTP) and subsequent refinement.

Appendix E: Editorial Guide: Style and Terms

To provide consistency and clarity, there has been an effort to use certain styles and specific terms within the Guide.
Although this has been the intent, it is the content of the Guide that has been the focus. Consequently, authors may
find instances where alternative styles or terms are used.

Style

Type Notes

Italics To emphasize a word in a sentence or phrase

To indicate the name of something

Upper case first letter To emphasize a word in a sentence or phrase not necessarily at the
beginning

Periods Not used in:

Don't do this

Lists when items contained therein are not sentences

At the end of sentences within tables

Examples Presented as:

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Style

For example,
text of example
When possible, examples from the SNOMED CT browser are
provided. When examples from the browser aren't available, i.e do
not yet exist, they are obtained from other sources

Macros: Note, Tip, Warning General

General
For example, For For more information
more information,
Modeling, Exception Contains general information or additional resource (may be
link).
Specific
For example,
Concepts, URLs
Optional Title - added to Modeling
each Contains modeling information.

Exception or Inactivation or Under

Revision
Contains information about content exceptions, inactivation, or
under revision

Specific

Concepts
Some concepts, for example, those in the Qualifier value
hierarchy, support the definition of other concepts.

URLs
URLs that point to definition sources are unacceptable.

Tables
Heading row
Heading row - light green
fill; bold font
Sub-heading row - light
blue fill
Column heading - light blue
fill
Other cells - may have pink
fill for emphasis Footing row

Footing row - light yellow

fill Note: Tables generated from the Human Readable Concept Model have
unique formatting

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Text formats Minimally used

"Quotation marks"
Bold font
All CAPS

Page headings Section headings - Heading 2

Subsection headings - Heading 3

Terms

Used in Guide Synonym / Other

Attribute Concept Model Attribute; Relationship type

Authoring platform SCA tool

Child Subtype, Subtype child

Classifier Description logic (DL) classifier; Logic reasoner

Descendant Child and Subtype child/children

Domain Concept model domain

Electronic health application Software application; Clinical information systems

Electronic health record or Electronic medical record; Electronic record; Electronic patient record
EHR

Extension SNOMED CT extension, Member/Affiliate-Added Terminology

Grouping concept/Grouper NA

Inactivate/Inactivation Retire*

International Release Core

Modeler/Modeling Author/Authoring, Editor/Editing

Parent Supertype, Supertype parent

Precoordinated Precoordinated expression

Postcoordinated Postcoordinated expression

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Terms

Qualifier Qualifying characteristic

Range Concept model range, Allowable value

Relationship group Role group

Root concept Top-level concept

Semantic tag Semantic type, Hierarchy tag

Situation with Explicit Context Context-dependent Category

Sufficiently defined Fully defined*

Supercategory ??

*Strikethrough = No longer used

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Previous Versions

This page provides access to downloadable PDF copies of the current and previous versions of this
document.
The most recent version should also be available via a link on the front page of the document.

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The most recently updated pages in this document are listed

below
Event Modeling (see page 149)4 minutes ago • updated by Krista Lilly • view change
Observable Entity Defining Attributes (see page 156)4 minutes ago • updated by Krista Lilly • view change
Organism* (see page 164)4 minutes ago • updated by Krista Lilly • view change
Organism Naming Conventions (see page 167)4 minutes ago • updated by Monica Harry • view change
Physical Object (see page 179)4 minutes ago • updated by Krista Lilly • view change
Procedure Modeling (see page 217)4 minutes ago • updated by Krista Lilly • view change
Specific Procedure Modeling (see page 219)4 minutes ago • updated by Monica Harry • view change
Procedure Naming Conventions (see page 203)4 minutes ago • updated by Krista Lilly • view change
Measurement Procedure Naming Conventions (see page 216)4 minutes ago • updated by Krista Lilly • view
change
Clinical Finding/Disorder Naming Conventions (see page 106)4 minutes ago • updated by Krista Lilly • view
change
Lateralized Disorder Naming Conventions (see page 111)4 minutes ago • updated by David Markwell • view
change
Specific Disorder Modeling (see page 113)4 minutes ago • updated by Monica Harry • view change
Disorder Combination Modeling (see page 135)4 minutes ago • updated by Monica Harry • view change
Complication and Sequela Modeling (see page 142)4 minutes ago • updated by Monica Harry • view change
Nutritional intake observable entities (see page 163)4 minutes ago • created by Krista Lilly
SNOMED CT Editorial Guide (see page 3)4 minutes ago • updated by Monica Harry • view change
Scope (see page 5)4 minutes ago • updated by David Markwell • view change
When Is Content Rejected? (see page 22)4 minutes ago • updated by Krista Lilly • view change
Definitions (see page 35)4 minutes ago • updated by Monica Harry • view change
Domain Specific Modeling (see page 67)4 minutes ago • updated by Krista Lilly • view change
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