Can SNOMED International represent patients' perceptions of health-related problems for the computer-based patient...

As the United States moves towards a computer-based patient record, there is much discussion related to the contents of such a record and the manner in which the data elements will be represented. Recent health care reform has emphasized the need for increased patient involvement in health care decision making, however, there has been little discussion about including the patient perspective in the computer-based patient record. Using an existing data set of 201 patients who were hospitalized for Pneumocystis carinii pneumonia, this study examined the ability of SNOMED International to represent patients' perceptions of health-related problems. The majority of concepts used by patients to describe health-related problems could be matched with existing SNOMED terms. The addition of the social context module as an adjunct to existing terminologies of medical diagnoses, NANDA diagnoses, and signs/symptoms provided additional matching terms. Patient goals did not match existing SNOMED terms. The findings of this study suggest that SNOMED International has the potential to adequately represent patients' perceptions of health-related problems for the computer-based patient record. Additional studies are needed that will examine the extent to which patients' perceptions of health-related problems are already documented in the patient record by healthcare providers. The utility of patients' perceptions of health-related problems in the prediction of patient outcomes must also be analyzed.