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The problem is that clinical documentation and communication is prepared by clinicians who need to say things quickly and precisely for example:

? #L nof, fell down stairs at home

also used for reporting purposes which require that same information to be coded and reported under different headings.

The solution is the SmartTermer. Special features:

• Includes postcoordination and link to (limited) reference sets thereby meeting clinical and reporting needs
• Supports misspellings and local meanings
• Includes consideration of patient details and context

The screen below shows the clinician’s text and the resultant codes in both SNOMED-CT (used for clinical communication and retains accuracy of all concepts entered) AND each of the relevant ICD codes indicating the fields into which they could be returned in the local system.

This screen shows that clinical data includes an injury, a cause, place of occurrence and other value types. The system is built to operate totally automatically (as in this case showing default values) or to provide a series of options to allow the user to indicate their meaning more specifically.