CAN SNOMED INTERNATIONAL REPRESENT PATIENTS PERCEPTIONS OF HEALTH-RELATED PROBLEMS FOR THE COMPUTER-BASED PATIENT RECORD

As the United States moves towards a computer-based patient record, th ere is much discussion related to the contents of such a record and th e 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 discus sion about including the patient perspective in the computer-based pat ient record. Using an existing data set of 201 patients who were hospi talized for Pneumocystis carinii pneumonia, this study examined the ab ility of SNOMED International to represent patients' perceptions of he alth-related problems. The majority of concepts used by patients to de scribe health-related problems could be matched with existing SNOMED t erms. The addition of the social context module as an adjunct to exist ing terminologies of medical diagnoses, NANDA diagnoses, and signs/sym ptoms 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' perc eptions of health-related problems for the computer-based patient reco rd. Additional studies are needed that will examine the extent to whic h patients' perceptions of health-related problems are already documen ted in the patient record by healthcare providers. The utility of pati ents' perceptions of health-related problems in the prediction of pati ent outcomes must also be analyzed.