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Related Concept Videos

Pharmacovigilance01:19

Pharmacovigilance

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Post-marketing surveillance is a critical component of pharmaceutical regulation, often uncovering unanticipated adverse drug reactions (ADRs) once a drug is widely used over an extended period.
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The nurse documents nursing diagnoses and enters them into the patient record. The identified patient's nursing diagnosis is either written out with a plan of care or entered into the electronic health record.
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Methods of Documentation V: CBE01:23

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Charting by Exception, or CBE, is a method of documentation used in healthcare, particularly in nursing, that focuses on documenting only significant or abnormal findings rather than recording every detail. This approach aims to streamline the documentation process, improve efficiency, and ensure that healthcare providers can quickly identify deviations from normalcy in patient assessments.
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Methods of Documentation VII: EMR01:30

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Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare...
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Quality documentation and reporting share essential characteristics that ensure they are practical and valuable resources for those who use them. These characteristics are:
Factual:  
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Developing a SNOMED CT-Based Value Set to Document Symptoms and Diagnoses for Adverse Drug Events: Mixed Methods

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  • 1Strategy, Planning and Implementation, BC Cancer, 601 West Broadway, Vancouver, BC, V5Z 4C2, Canada, 1 6048776000.

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Summary

A new SNOMED CT value set standardizes adverse drug event (ADE) documentation in electronic medical records (EMRs). This improves data integration and patient safety by reducing repeat ADEs.

Keywords:
SNOMED CTadverse drug eventelectronic medical recordspharmacovigilanceterminology standard

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Area of Science:

  • Health Informatics
  • Clinical Terminology
  • Pharmacovigilance

Background:

  • Adverse drug events (ADEs) cause significant patient harm and healthcare costs in Canada, with over 2 million emergency department visits annually.
  • Effective documentation and sharing of ADE information via electronic medical records (EMRs) are crucial for patient safety.
  • Current EMR systems often lack standardized value sets for comprehensive ADE documentation.

Purpose of the Study:

  • To develop a SNOMED CT value set for standardizing the documentation of ADE symptoms and diagnoses.
  • To improve ADE data integration into EMRs for better patient care and safety.

Main Methods:

  • Utilized ADE data from the prospective ActionADE reporting system across 9 British Columbia hospitals.
  • Mapped 827 unique ADE terms to SNOMED CT concepts using automated and manual approaches.
  • Validated mappings with clinical experts and a quality assurance team, resolving discrepancies through consensus.

Main Results:

  • Successfully mapped 98.4% of source terms to SNOMED CT concepts, creating a final value set of 813 concepts.
  • Achieved strong interrater reliability (κ=0.87-0.88) during mapping and validation.
  • The final value set consists of 95.7% semantically equivalent and 4.3% semantically similar SNOMED CT concepts.

Conclusions:

  • Developed a standardized SNOMED CT value set for documenting adult ADE symptoms and diagnoses in EMRs.
  • Adoption of this value set can enhance consistency, accuracy, and interoperability of ADE documentation, reducing repeat events and improving patient safety.
  • Ongoing refinement and usability assessments are vital for widespread adoption; future research should evaluate its impact on ADE reporting and patient outcomes.