What is recorded as a SNOMED code on the patient's record?
Demographics
Gender
Sexual Orientation
Religion
Ethnicity
Country of birth
First arrival into the UK
Special circumstances
Interpreter needed
Interpreter language required
Armed Forces
Armed Forces role
Attending an educational institution
Type of educational institution
Fostered
Has a social worker
Lives in a care home
Lives in a nursing home
Out of area
Other
Summary Care Record consent
Preferred contact method
Can be contacted for updates about the practice
Consent to being part of the patient participation group (PPG)
Allocated named accountable general practitioner
Informed of their named accountable general practitioner
Medical
Disability
Weight
Height
Exercise frequency
Smoking status
Smoking frequency
Smoking cessation advice
Alcohol status (AUDIT-C)
Offered HIV test
Pregnancy
Family history
What is not recorded as a SNOMED code on the patient's record?
💊 Repeat medications because this information could be inaccurate and practices have different processes for handling repeat medication.
🩺 Allergies and long-term conditions because if these are coded incorrectly it can have consequences for a patient's record and QOF.
📑 Documents because we don't currently upload these to the clinical record.
‼️ For any information that is not SNOMED coded, we leave a consultation note in the patient's record with the relevant details. Additionally, we place a signal on the form to alert the practice that the information needs to be reviewed.
This ensures that important information is captured and flagged for review, even if it cannot be directly SNOMED coded.