Center for Biomedical Informatics, Mt. Sinai School of Medicine, New York, NY, USA.
J Trauma Stress. 2010 Dec;23(6):794-801. doi: 10.1002/jts.20591. Epub 2010 Nov 19.
The authors sought to evaluate how well the Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT) controlled vocabulary represents terms commonly used clinically when documenting posttraumatic stress disorder (PTSD). A list was constructed based on the PTSD criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American Psychiatric Association, 1994), symptom assessment instruments, and publications. Although two teams mapping the terms to SNOMED-CT differed in their approach, the consensus mapping accounted for 91% of the 153 PTSD terms. They found that the words used by clinicians in describing PTSD symptoms are represented in SNOMED-CT. These results can be used to codify mental health text reports for health information technology applications such as automated chart abstraction, algorithms for identifying documentation of symptoms representing PTSD in clinical notes, and clinical decision support.
作者试图评估《医学系统命名法-临床术语》（SNOMED-CT）受控词汇在记录创伤后应激障碍（PTSD）时，对临床上常用术语的代表性如何。根据《精神障碍诊断与统计手册》第四版（DSM-IV；美国精神病学协会，1994 年）中的 PTSD 标准、症状评估工具和出版物，编制了一份清单。尽管将这些术语映射到 SNOMED-CT 的两个团队的方法有所不同，但共识映射涵盖了 153 个 PTSD 术语的 91%。他们发现，描述 PTSD 症状的临床医生所用的词语在 SNOMED-CT 中都有体现。这些结果可用于对心理健康文本报告进行编码，以便应用于健康信息技术，例如自动图表提取、用于识别临床记录中代表 PTSD 的症状文档的算法，以及临床决策支持。
