Hi @mikael , interesting, I didn’t know about snomed default contexts. Thank you for educating me.
I read the default context for a finding (e.g. UTI) to be:
* The finding has actually occurred (vs. being absent or not found).
* It is occurring to the subject of the record (the patient).
* It is occurring currently or at a stated past time.
But this still leaves a lot of context out to be able to you need to programatically conclude a patient ‘has’ a UTI. e.g. is it a diagnosis? who made the diagnosis (doctor/nurse/neighbour/facebook)? Is the diagnosis clinically significant or just a mild bacteriuria. etc. etc.
Otherwise we wouldn’t need information models at all, right?
The downside of this default context is that terms that do not match that context ‘family history of UTI’ are not codedable in snomed.
The search and data entry guide sure seems interesting. Any recomandation how to approach it? Aside from start at page 1 and spent multiple weekend days before you end up at page 65? (a)
I do now better appreciated Ian’s concern about automated snomed encoding. But this is also goes for average users, they won’t understand default context, which means the scope of usage of snomed is much smaller than I hoped.