SNOMED-CT Clinical Problem and Body Structure Concepts

NextGen® Enterprise EHR Help

Diagnosis Codes

This section provides information on: Validation and expiration for diagnosis codes you assign from template triggers. How to quickly find and select the appropriate ICD Billing code for a patient diagnosis using a template Pop-Up trigger. Diagnosis Expiration and Validation Select the Medical Necessity Diagnosis Code ICD-SNOMED Mapping Parent topic: Using Templates Related concepts Access Rights to Medical Records

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Search for a SNOMED-CT Body Structure Concept ID

You can launch the SNOMED-CT body structure search window from a Body Structure Pop-Up trigger on a template which enables you to search for and select a SNOMED-CT concept ID from the body structure hierarchy. Enter the body structure description in full or in part in the text box at the top. Select Search, or select the Enter key. The search results grid displays a list of synonyms for the search term entered. The synonyms are displayed in three columns by Description, Fully Specified Name, and Concept ID. Note: Up to 100 results are displayed at a time. If over 100 results are available, a message appears. Refine the search term to display fewer, more specific results. Do the following as per your requirement: To change the column order, drag the column header left or right. To adjust the width of a column, drag the vertical column border in or out. To switch between ascending and descending alphabetical or numerical order in a column, select the column heading. You can also view, ad

NextGen® Enterprise EHR Help

Problem List

The Problem List tab enables you to view the details of the active, inactive, resolved, and unresolved problems of a patient and update them as needed. You can record and update a patient’s problems using the Systemized Nomenclature of Medicine - Clinical Terms (SNOMED-CT®) concept. SNOMED-CT® is a standard vocabulary used to express clinical terms. SNOMED-CT® is comprised of descriptive terms or synonyms related to a clinical concept and provides links between different concepts. The problem list is demographic and is not associated with an encounter. After you record a problem if you need to use it as a diagnosis for billing, you must add the problem to the billing ICD list. Problem List View and modify the details of problems in the problem list. Problem List Data Entry Area The problem list data entry area displays options for managing patient problems. Managing Problems and ICD Codes Parent topic: Diagnosing Patient Problem

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SNOMED Codes

Quality Reporting Stage 2 regulations require a patient’s chronic problems to be coded using SNOMED . The Systematized Nomenclature of Medicine - Clinical Terms ( SNOMED CT®) is a comprehensive collection of clinical terminology that was originally created by the College of American Pathologists. It contains healthcare concepts with unique meanings and formal, logic-based definitions organized into hierarchies. The SNOMED Codes provides the ability to consistently index, store and retrieve clinical data across specialties and sites of care. The SNOMED information is mapped to ICD codes. You can generate reports or export the information to support administrative and clinical reporting as well as reimbursement processes. Parent topic: Create and Manage SNOMED Codes

NextGen® Enterprise EHR Help

ICD-SNOMED Mapping

The ICD SNOMED Map template trigger enables you to view and assign the: ICD codes mapped to a selected SNOMED-CT problem to today's assessment or encounter. If only one ICD code is associated with the selected SNOMED-CT problem, the ICD description, ICD diagnosis code ID,and the ICD code are automatically assigned to the selected variable or template field. If more than one ICD code is associated with the selected SNOMED-CT problem, you must select an ICD code from the Select Mapped ICD Code window to assign the ICD description, ICD diagnosis code ID,and the ICD code to a variable or a template field. SNOMED concept IDs mapped to a selected ICD code to the patient's clinical problem list. If only one SNOMED-CT problem is associated with the selected ICD code, the SNOMED-CT concept ID, description, and fully specified name are automatically assigned to the selected variable or template field. If more than one SNOMED-CT problem is associated with the selected ICD code, you must select a

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Access Clinical Decision Support from the Problems Module

You can access the Clinical Decision Support resource from the Problems module. The Clinical Decision Support resource collects ICD-9, ICD-10 (as available), or SNOMED CT code information for the selected problem and the patient’s age, age range, and gender. The information is passed through the InfoButton to the external system. Open the Problems module for a patient. Enter a new problem in the Problem List tab or the Billing ICD List tab, if required. Note: The Problem List tab has the SNOMED CT term while the Billing ICD List tab has the ICD-9, or where applicable, ICD-10 code. Do one of the following: Right-click the problem, and then select Resources > Clinical Decision Support. Select the problem, and then select Resources > Clinical Decision Support from the Problems module toolbar. The application directs you to the external URL set up in File Maintenance. Parent topic: Clinical Decision Support

SNOMED-CT Clinical Problem and Body Structure Concepts

Recommendations

Diagnosis Codes

Search for a SNOMED-CT Body Structure Concept ID

Problem List

SNOMED Codes

ICD-SNOMED Mapping

Access Clinical Decision Support from the Problems Module

Diagnosis Codes

Search for a SNOMED-CT Body Structure Concept ID

Problem List

SNOMED Codes

ICD-SNOMED Mapping

Access Clinical Decision Support from the Problems Module