The iSalut Clinical Dictionary is a transversal project of the Department of Health managed by the OFSTI, whose objective is to normalize SISCAT’s vocabulary so that semantic interoperability can be achieved between providers’ information systems at different levels healthcare. The base of the Dictionary is the clinical terminology SNOMED CT, which acts as an ontology and a homogeneous representation base, although it also contains other vocabularies that are already used at SISCAT (eg LOINC, ISCO/CNO, SERAM, SEMNim, etc.).
The technical part of the Dictionary is also led by the OFSTI, while the catalog area of the eSalut Office of the General Coordination of ICT directs the functional part. The priorities and actions to follow in the Dictionary are marked by the Permanent Commission formed by representatives of different providers, CatSalut and the Department of Health, among others.
The iSalut Clinical Dictionary is organized in content domains, each of which is worked by a multidisciplinary team and at the level of subgroups, following the creation methodology of subsets defined by the OFSTI. In this way, the Dictionary has the participation of healthcare professionals from different centers, programs and institutions, the detailed list of which can be consulted in the documentation of each domain.
The dictionary domains that are currently available are listed below:
- Allergies (ES): Subsets of SNOMED CT that contain disorders and allergic manifestations, differentiating if the type of causative agent is medicamentous, alimentary or another type.
- Pathological anatomy (ES): Subset and microglossary of SNOMED CT that contains the most frequent concepts of pathological anatomy such as morphologies or topologies.
- Procedure qualifiers (ES and CAT): Subsets of SNOMED CT that contain the necessary concepts to complement the radiology procedure qualifiers: laterality, position / projection / functional, radiological contrast and anatomical location.
- Clinical documents (ES): Subset of SNOMED CT that contains the list of documents that can be published in the Shared Cclinical History of Catalonia (HCCC).
- Assessment scales (ES and CAT): Subset of SNOMED CT that contains the assessment scales, especially in the geriatrics and chronicity areas.
- Surgical sheet (CAT): Recommendation document detailing the information that the surgical sheet must have in order to structure the procedures in this area based on the CIM-10-MC/SCP classification. The document can be consulted in the following link: Recommendation of minimum surgical sheet information.
- Immunizations (ES and CAT): A subset of SNOMED CT that contains active and passive immunizations and, therefore, immunoglobulins and immune serum.
- Spirometry report (ES): Subset of SNOMED CT that contains the concepts necessary to structure the fields and content of the spirometry report that can be published at the HCCC.
- Cancer screening report (ES and CAT): A subset of SNOMED CT that contains the concepts necessary to structure the fields and content of the cancer screening report that can be published at the HCCC.
- Laboratory (CAT): A subset of comparable LOINC tests to be tracked independently from the center that performs them (through HCCC), and a subset of single LOINC tests, which are only performed once in the patient’s life (also available at HCCC). The subset of comparable tests includes the part of serology corresponding to the publication of microbiology in Public Health.
- Microbiology (ES): Subsets of SNOMED CT that contain the concepts necessary for the notification of microbiology to Public Health. The part of serology is worked in the field of laboratory.
- Notification of adverse reactions to immunizations (ES): A subset of SNOMED CT that contains the necessary concepts to represent the information of notification of adverse reactions to Immunizations in Public Health.
- Ophthalmology and neurology (ES): Subsets of SNOMED CT that contain the concepts related to ophthalmic and neurological examinations.
- Procedures (ES and CAT): This domain is made up of three different controlled vocabularies that allow to represent the procedures that can be made in primary care by a nurse, a pediatrician or a doctor, in addition to those that can be derived from primary and specialized care, as well as from specialized care centers:
- Health professions (ES and CAT): Subset of SNOMED CT that contains groups of health professionals.
- Assistance services, specialties and functional units (CAT): Unified health services, medical and nursing specialties catalogs and functional units, available in Catalan at the following link: Catalog of services, specialties and units.
- Clinical variables (ES and CAT): Subset of SNOMED CT that contains the clinical variables to be monitored independently from the center that performs them (through HCCC).
- WiFIS (ES): Grouping SNOMED CT concepts specific to WiFIS messaging using the IS3 project. The associated subsets are available in Spanish.
In the download area of SNOMED CT you can obtain all the subconjunctions of SNOMED CT from the Clinical Dictionary for iSalut, as well as its associated documentation.