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Data Reporting and Recording

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Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...

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Updated: May 12, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

Implementing SNOMED CT for Quality Reporting: Avoiding Pitfalls.

¹Clinical Informatics Consulting , Atlanta, GA, USA.

Applied Clinical Informatics

|April 26, 2013

Summary

This summary is machine-generated.

Implementing SNOMED CT electronic specifications for quality measures revealed critical content errors. Rigorous review and edits are essential to prevent incorporating flawed data into electronic health record systems.

Keywords:

SNOMED CT electronic health records national health policy

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Last Updated: May 12, 2026

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

A Metadata Extraction Approach for Clinical Case Reports to Enable Advanced Understanding of Biomedical Concepts

Published on: September 20, 2018

Area of Science:

Health Informatics
Medical Terminology Standards
Quality Measurement

Background:

Centers for Medicare and Medicaid Services (CMS) mandates standardized electronic specifications for quality measure reporting.
These specifications aim to incentivize eligible providers through financial incentives.
Vendors and hospital systems must adopt these standardized data elements.

Purpose of the Study:

To implement SNOMED CT electronic specifications for quality measures.
To identify critical issues impacting the implementation of these specifications.
To ensure accurate data for quality reporting and financial incentives.

Main Methods:

Downloaded and extracted CMS electronic specifications.
Examined 10,643 SNOMED CT codes for 44 quality measures.
Created a mapping table for EHR system integration.
Conducted qualitative and quantitative evaluations of SNOMED CT codes.

Main Results:

Identified significant content aberrancies in approved SNOMED CT code sets.
Issues include incomplete IDs, use of description IDs, inactive codes, and non-human content.
Morphology and observable codes were inappropriately included for clinical findings.

Conclusions:

Approved SNOMED CT specifications contain errors requiring correction.
Implementers must conduct rigorous reviews and edits before system integration.
Failure to address these issues risks incorporating errors into EHR products and systems.