title: Comparison of Knowledge Levels Required for SNOMED CT Coding of Diagnosis and Operation Names in Clinical Records.
abstract: OBJECTIVE
  Coding Systematized Nomenclature of Medicine, Clinical Terms (SNOMED CT) with complex and polysemy clinical terms may ask coder to have a high level of knowledge of clinical domains, but with simpler clinical terms, coding may require only simpler knowledge. However, there are few studies quantitatively showing the relation between domain knowledge and coding ability. So, we tried to show the relationship between those two areas.
  
  
  METHODS
  We extracted diagnosis and operation names from electronic medical records of a university hospital for 500 ophthalmology and 500 neurosurgery patients. The coding process involved one ophthalmologist, one neurosurgeon, and one medical record technician who had no experience of SNOMED coding, without limitation to accessing of data for coding. The coding results and domain knowledge were compared.
  
  
  RESULTS
  705 and 576 diagnoses, and 500 and 629 operation names from ophthalmology and neurosurgery, were enrolled, respectively. The physicians showed higher performance in coding than in MRT for all domains; all specialist physicians showed the highest performance in domains of their own departments. All three coders showed statistically better coding rates in diagnosis than in operation names (p < 0.001).
  
  
  CONCLUSIONS
  Performance of SNOMED coding with clinical terms is strongly related to the knowledge level of the domain and the complexity of the clinical terms. Physicians who generate clinical data can be the best potential candidates as excellent coders from the aspect of coding performance.
authors.affiliation: Department of Laboratory Medicine, Pusan National University School of Medicine, Busan, Korea. ; Medical Research Institute, Pusan National University Hopital, Busan, Korea.
authors.forename: Shine Young
authors.initials: SY
authors.lastname: Kim
authors.forename: Hyung Hoi
authors.initials: HH
authors.lastname: Kim
authors.forename: Kyung Hwa
authors.initials: KH
authors.lastname: Shin
authors.forename: Hwa Sun
authors.initials: HS
authors.lastname: Kim
authors.forename: Jae Il
authors.initials: JI
authors.lastname: Lee
authors.forename: Byung Kwan
authors.initials: BK
authors.lastname: Choi
keywords: Clinical Coding; Diagnosis; Knowledge; Operations; Systematized Nomenclature of Medicine