Clinical Assessment
The first step in delivering comprehensive care is to undertake a clinical assessment. Clinical assessment data which can be recorded using SNOMED CT includes:
Symptoms
Severity
Clinical Measurements
Clinical Examination Findings
Diagnosis and Certainty
Clinical History
Secondary Conditions and Complications
Potential Risk Factors
Comorbidities
Exposure Event
Covid-19 and Viral Co-Infections
These data elements are described below, with example SNOMED CT subsets for each.
Please note that all published concepts referred to on this page are included in SNOMED International's Global Patient Set (GPS), which is available to be used internationally under the Creative Commons Attribution 4.0 International License. Please refer to http://snomed.org/covid-19 for more information.
Symptoms
Symptoms represent physical or mental features which are regarded as an indication of a condition or disease, particularly those features that are apparent to the patient. This SNOMED CT subset of COVID-19 symptoms has been developed based on a range of literature, including relevant articles found in Pubmed, research performed by Kings College London, and a review of COVID-19 data collection forms. Please note that this subset includes the concept 84387000 | Asymptomatic (finding)| , which can be used to represent the absence of symptoms.
CV19-ASS-Symptoms
21522001
Abdominal pain (finding)
Abdominal pain
20050131
84387000
Asymptomatic (finding)
Asymptomatic
20020131
131148009
Bleeding (finding)
Bleeding
20050131
29857009
Chest pain (finding)
Chest pain
20040731
43724002
Chill (finding)
Chill
20020131
82272006
Common cold (disorder)
Common cold
20030131
9826008
Conjunctivitis (disorder)
Conjunctivitis
20040731
49727002
Cough (finding)
Cough
20020131
3415004
Cyanosis (finding)
Cyanosis
20020131
62315008
Diarrhea (finding)
Diarrhea
20020131
3006004
Disturbance of consciousness (finding)
Disturbance of consciousness
20020131
267036007
Dyspnea (finding)
Dyspnea
20020131
271807003
Eruption of skin (disorder)
Eruption
20020731
84229001
Fatigue (finding)
Fatigue
20020131
103001002
Feeling feverish (finding)
Feeling feverish
20020131
386661006
Fever (finding)
Fever
20030131
25064002
Headache (finding)
Headache
20100131
66857006
Hemoptysis (finding)
Hemoptysis
20020131
248567008
Indrawing of ribs during respiration (finding)
Indrawing of ribs during respiration
20020131
57676002
Joint pain (finding)
Joint pain
20020131
79890006
Loss of appetite (finding)
Loss of appetite
20020131
44169009
Loss of sense of smell (finding)
Loss of sense of smell
20200131
36955009
Loss of taste (finding)
Loss of taste
20020131
30746006
Lymphadenopathy (disorder)
Lymphadenopathy
20020131
367391008
Malaise (finding)
Malaise
20020131
68962001
Muscle pain (finding)
Muscle pain
20020131
26544005
Muscle weakness (finding)
Muscle weakness
20020131
68235000
Nasal congestion (finding)
Nasal congestion
20020131
64531003
Nasal discharge (finding)
Nasal discharge
20020131
422587007
Nausea (finding)
Nausea
20070131
44077006
Numbness (finding)
Numbness
20170731
162397003
Pain in throat (finding)
Pain in throat
20020131
38880002
Rigor (finding)
Rigor
20020131
91175000
Seizure (finding)
Seizure
20020131
46742003
Skin ulcer (disorder)
Skin ulcer
20020131
23924001
Tight chest (finding)
Tight chest
20020131
282145008
Unable to walk (finding)
Unable to walk
20080731
422400008
Vomiting (disorder)
Vomiting
20180731
56018004
Wheezing (finding)
Wheezing
20020131
Severity
Severity represents the quality of the condition - for example, 24484000 | Severe (severity modifier) (qualifier value)| . Severity may be recorded for each symptom, or as a general statement of their disease state 4.
CV19-ASS-Severity
84387000
Asymptomatic (finding)
Asymptomatic
20020131
255604002
Mild (qualifier value)
Mild
20020131
6736007
Moderate (severity modifier) (qualifier value)
Moderate
20020131
24484000
Severe (severity modifier) (qualifier value)
Severe
20020131
442452003
Life threatening severity (qualifier value)
Life threatening severity
20090731
Clinical Measurements
Clinical measurements involve the performance of physiological tests to diagnose and refine therapeutic management of an already established disease. The following clinical measurements (and related observables) can be used in the assessment of a COVID-19 patient.
CV19-ASS- ClinicalMeasurements
413384008
Ability to perform cognitive activity (observable entity)
Ability to perform cognitive activity
20050131
442476006
Arterial oxygen saturation (observable entity)
Arterial oxygen saturation
20090731
386725007
Body temperature (observable entity)
Body temperature
20170131
75367002
Blood pressure (observable entity)
Blood pressure
20170131
248592006
Character of cough (observable entity)
Character of cough
20020131
364533002
Color of skin (observable entity)
Color of skin
20020131
709017009
Compliance behavior to safety precaution (observable entity)
Compliance behavior to safety precaution
20150731
263731006
Coughing (observable entity)
Coughing
20020131
271626009
Depth of respiration (observable entity)
Depth of respiration
20020131
226379006
Food intake (observable entity)
Food intake
20020131
364075005
Heart rate (observable entity)
Heart rate
20170131
103228002
Hemoglobin saturation with oxygen (observable entity)
Hemoglobin saturation with oxygen
20020131
6942003
Level of consciousness (observable entity)
Level of consciousness
20020131
440398005
Level of fatigue (observable entity)
Level of fatigue
20090131
405161002
Pain level (observable entity)
Pain level
20040131
248750004
Peripheral blood flow (observable entity)
Peripheral blood flow
20020131
431314004
Peripheral oxygen saturation (observable entity)
Peripheral oxygen saturation
20080731
8499008
Pulse, function (observable entity)
Pulse
20020131
248565000
Respiratory effort (observable entity)
Respiratory effort
20020131
86290005
Respiratory rate (observable entity)
Respiratory rate
20170131
248582003
Rhythm of respiration (observable entity)
Rhythm of respiration
20020131
247433003
Skin elasticity (observable entity)
Skin elasticity
20020131
248598005
Sputum volume (observable entity)
Sputum volume
20020131
442349007
Venous oxygen saturation (observable entity)
Venous oxygen saturation
20090731
Clinical Examination Findings
Clinical examination findings are the result of measuring, questioning, evaluating, or otherwise examining a patient in healthcare. The following clinical findings are positive or negative indications that signs are present in a COVID-19 patient.
CV19-ASS-ClinicalExaminationFindings
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
288848001
Able to breathe (finding)
Able to breathe
20080731
77427003
Activity intolerance (finding)
Activity intolerance
20020131
20262006
Ataxia (finding)
Ataxia
20020131
371632003
Coma (disorder)
Coma
20020731
193894004
Conjunctival hyperemia (finding)
Conjunctival hyperemia
20100131
58840004
Decreased breath sounds (finding)
Decreased breath sounds
20020131
443371007
Decreased level of consciousness (finding)
Decreased level of consciousness
20100131
9763007
Expiratory wheezing (finding)
Expiratory wheezing
20020131
126664009
Exudative pharyngitis (disorder)
Exudative pharyngitis
20020131
386661006
Fever (finding)
Fever
20030131
442646005
Imaging of lung abnormal (finding)
Imaging of lung abnormal
20090731
67750007
Ineffective airway clearance (finding)
Ineffective airway clearance
20020131
70944005
Impaired gas exchange (finding)
Impaired gas exchange
20080731
75252003
Inspiratory crackles (finding)
Inspiratory crackles
20020131
419045004
Loss of consciousness (finding)
Loss of consciousness
20060131
274710003
Lung field abnormal (finding)
Lung field abnormal
20020131
91175000
Seizure (finding)
Seizure
20020131
3424008
Tachycardia (finding)
Tachycardia
20080731
271823003
Tachypnea (finding)
Tachypnea
20020131
288849009
Unable to breathe (finding)
Unable to breathe
20080731
Diagnosis and Certainty
A diagnosis is the identification of the nature of the illness, based on an examination of the symptoms, observations, measurements, test results and other investigation results. The following subset includes a range of diagnoses directly related to COVID-19.
CV19-ASS-Diagnosis
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
1119302008
Acute disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Acute COVID-19
20210131
189486241000119100
Asymptomatic severe acute respiratory syndrome coronavirus 2 infection (finding)
Asymptomatic SARS-CoV-2
20200731
840539006
Disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
COVID-19
20200131
688232241000119100
Disease caused by Severe acute respiratory syndrome coronavirus 2 absent (situation)
Disease caused by Severe acute respiratory syndrome coronavirus 2 absent
20200731
840544004
Suspected disease caused by severe acute respiratory coronavirus 2 (situation)
Suspected COVID-19
20200131
To represent the certainty of a positive COVID-19 diagnosis, the following subset may be used in conjunction with a diagnosis of 840539006 | COVID-19| .
CV19-ASS-DiagnosisPresentCertainty
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
410605003
Confirmed present (qualifier value)
Confirmed present
20040731
410592001
Probably present (qualifier value)
Probably present
20040731
415684004
Suspected (qualifier value)
Suspected
20050131
To represent the certainty of the absence of COVID-19, the following subset may be used in conjunction with a diagnosis of 688232241000119100 | Disease caused by severe acute respiratory syndrome coronavirus 2 absent (situation)| .
CV19-ASS-DiagnosisAbsentCertainty
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
410594000
Definitely NOT present (qualifier value)
Definitely NOT present
20040731
410593006
Probably NOT present (qualifier value)
Probably NOT present
20040731
Clinical History
The clinical history concepts are used to record information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information, with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient.
CV19-ASS-ClinicalHistory
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
In GPS
292508471000119105
History of disease caused by severe acute respiratory syndrome coronavirus 2 (situation)
History of SARS-CoV-2
20200731
-
Secondary Conditions and Complications
A secondary condition is any additional health condition that occurs as a result of the natural progression or expected outcome of the primary condition. A complication is "a disorder caused by another disorder, procedure or event, which is not a natural progression or expected outcome of its cause .
The following subset includes SNOMED CT clinical findings that may be recorded as either secondary conditions or complications . Clinical judgement is required to determine whether these conditions are expected outcomes or unexpected complications of COVID-19.
CV19-ASS-SecondaryConditionsAndComplications
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
138389411000119105
Acute bronchitis caused by severe acute respiratory syndrome coronavirus 2 (disorder)
Acute bronchitis caused by SARS-CoV-2
20200731
870590002
Acute hypoxemic respiratory failure due to disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Acute hypoxemic respiratory failure due to disease caused by Severe acute respiratory syndrome coronavirus 2
20200731
870589006
Acute kidney injury due to disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Acute kidney injury due to disease caused by Severe acute respiratory syndrome coronavirus 2
20200731
373895009
Acute respiratory distress (finding)
Acute respiratory distress
20020731
67782005
Acute respiratory distress syndrome (disorder)
Acute respiratory distress syndrome
20020131
674814021000119106
Acute respiratory distress syndrome due to disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Acute respiratory distress syndrome due to disease caused by Severe acute respiratory syndrome coronavirus 2
20200731
64779008
Blood coagulation disorder (disorder)
Blood coagulation disorder
20020731
119731000146105
Cardiomyopathy due to disease caused by Severe acute respiratory syndrome virus 2 (disorder)
Cardiomyopathy due to disease caused by Severe acute respiratory syndrome virus 2
20200731
62914000
Cerebrovascular disease (disorder)
Cerebrovascular disease
20020131
1119304009
Chronic post-COVID-19 syndrome (disorder)
Chronic post-COVID-19 syndrome
20210131
119741000146102
Conjunctivitis due to disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Conjunctivitis due to disease caused by Severe acute respiratory syndrome coronavirus 2
20200731
710027002
Cytokine-associated toxicity (disorder)
Cytokine release syndrome
20150731
419099009
Dead (finding)
Dead
20060131
128053003
Deep venous thrombosis (disorder)
Deep venous thrombosis
20020131
34095006
Dehydration (disorder)
Dehydration
20020131
67406007
Disseminated intravascular coagulation (disorder)
Disseminated intravascular coagulation
20020131
3006004
Disturbance of consciousness (finding)
Disturbance of consciousness
20020131
119981000146107
Dyspnea caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Dyspnea caused by Severe acute respiratory syndrome coronavirus 2
20200731
1240561000000108
Encephalopathy due to disease caused by Severe acute respiratory syndrome virus 2 (disorder)
Encephalopathy due to disease caused by Severe acute respiratory syndrome virus 2
20200731
119751000146104
Fever caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Fever caused by Severe acute respiratory syndrome coronavirus 2
20200731
25374005
Gastroenteritis (disorder)
Gastroenteritis
20020131
56265001
Heart disease (disorder)
Heart disease
20020131
80394007
Hyperglycemia (disorder)
Hyperglycemia
20020131
389086002
Hypoxia (disorder)
Hypoxia
20030131
70944005
Impaired gas exchange (finding)
Impaired gas exchange
20080731
1240541000000107
Infection of upper respiratory tract caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Infection of upper respiratory tract caused by Severe acute respiratory syndrome coronavirus 2
20200731
90708001
Kidney disease (disorder)
Kidney disease
20020731
880529761000119102
Lower respiratory infection caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Lower respiratory infection caused by SARS-CoV-2
20200731
866151004
Lymphocytopenia due to Severe acute respiratory syndrome coronavirus 2 (disorder)
Lymphocytopenia due to Severe acute respiratory syndrome coronavirus 2
20200731
59455009
Metabolic acidosis (disorder)
Metabolic acidosis
20020131
57653000
Multiple organ failure (disorder)
Multiple organ failure
20020131
1240531000000103
Myocarditis due to disease caused by Severe acute respiratory syndrome virus 2 (disorder)
Myocarditis due to disease caused by Severe acute respiratory syndrome virus 2
20200731
1240521000000100
Otitis media due to disease caused by Severe acute respiratory syndrome virus 2 (disorder)
Otitis media due to disease caused by Severe acute respiratory syndrome virus 2
20200731
183676005
Died in hospital (finding)
Died in hospital
20020131
882784691000119100
Pneumonia caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Pneumonia caused by SARS-CoV-2
20200731
1119303003
Post-acute COVID-19 (disorder)
Post-acute COVID-19
20210131
870591003
Rhabdomyolysis due to disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Rhabdomyolysis due to disease caused by Severe acute respiratory syndrome coronavirus 2
20200731
302846007
Rhabdomyoma (disorder)
Rhabdomyoma
20040731
308906005
Secondary bacterial pneumonia (disorder)
Secondary bacterial pneumonia
20160131
91302008
Sepsis (disorder)
Sepsis
20200131
870588003
Sepsis due to disease caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
Sepsis due to disease caused by Severe acute respiratory syndrome coronavirus 2
20200731
76571007
Septic shock (disorder)
Septic shock
20050131
415623008
Stress ulcer (disorder)
Stress ulcer
20050131
238149007
Systemic inflammatory response syndrome (disorder)
Systemic inflammatory response syndrome
20020131
866152006
Thrombocytopenia due to Severe acute respiratory syndrome coronavirus 2 (disorder)
Thrombocytopenia due to Severe acute respiratory syndrome coronavirus 2
20200731
429340002
Traumatic injury of skeletal muscle (disorder)
Traumatic injury of skeletal muscle
20080131
75570004
Viral pneumonia (disorder)
Viral pneumonia
20130731
1017214008
Viremia caused by Severe acute respiratory syndrome coronavirus 2 (disorder)
SARS-CoV-2 viremia
20210131
Potential Risk Factors
Potential risk factors are the patient conditions which may influence the course or outcomes of the COVID-19 disease. The following clinical findings may be recorded as potential risk factors.
CV19-ASS-RiskFactors
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
78648007
At risk for infection (finding)
At risk for infection
20020131
27624003
Chronic disease (disorder)
Chronic disease
20020131
49601007
Disorder of cardiovascular system (disorder)
Disorder of cardiovascular system
20020131
414029004
Disorder of immune function (disorder)
Disorder of immune function
20190131
235856003
Disorder of liver (disorder)
Disorder of liver
20020131
118940003
Disorder of nervous system (disorder)
Disorder of nervous system
20020131
50043002
Disorder of respiratory system (disorder)
Disorder of respiratory system
20020131
722499006
Electronic cigarette user (finding)
Electronic cigarette user
20170131
8517006
Ex-smoker (finding)
Ex-smoker
20020131
80141007
Hemoglobinopathy (disorder)
Hemoglobinopathy
20020131
107921000119107
History of immune disorder (situation)
History of immune disorder
20150731
90708001
Kidney disease (disorder)
Kidney disease
20020731
363346000
Malignant neoplastic disease (disorder)
Malignant neoplastic disease
20020131
75934005
Metabolic disease (disorder)
Metabolic disease
20020131
414825006
Neoplasm of hematopoietic cell type (disorder)
Neoplasm of hematopoietic cell type
20050131
414915002
Obese (finding)
Obese
20050131
370388006
Patient immunocompromised (finding)
Patient immunocompromised
20020731
370391006
Patient immunosuppressed (finding)
Patient immunosuppressed
20020731
77386006
Pregnant (finding)
Pregnant
20020131
77176002
Smoker (finding)
Smoker
20020131
Similarly, procedures performed on the patient within a clinically relevant timeframe may also influence the course or outcomes of the COVID-19 disease. The following procedures may be recorded as potential risk factors.
CV19-ASS-ProcedureRiskFactors
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
367336001
Chemotherapy (procedure)
Chemotherapy
20020131
788751009
Corticosteroid and corticosteroid derivative therapy (procedure)
Corticosteroid and corticosteroid derivative therapy
20200131
234336002
Hemopoietic stem cell transplant (procedure)
Hemopoietic stem cell transplant
20050131
86553008
Immunosuppressive therapy (procedure)
Immunosuppressive therapy
20020131
76334006
Immunotherapy (procedure)
Immunological therapy
20020131
108290001
Radiation oncology AND/OR radiotherapy (procedure)
Radiation oncology AND/OR radiotherapy
20020131
312235007
Radiolabeled antibody therapy (procedure)
Radiolabeled antibody therapy
20020131
265764009
Renal dialysis (procedure)
Renal dialysis
20020131
313039003
Solid organ transplant (procedure)
Solid organ transplant
20060731
Comorbidities
Comorbidities are additional medical conditions of concern. The following SNOMED CT subset can be used to record comorbidities.
CV19-ASS-Comorbidities
Intensional Definition:
Exposure
An exposure event is when an individual comes into close contact with an infected person's contaminated droplets, carried in the air or on contaminated hands, surfaces or other objects. The subset below includes SNOMED CT events for recording exposure to COVID-19.
CV19-ASS-ExposureEvent
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
840546002
Exposure to severe acute respiratory syndrome coronavirus 2 (event)
Exposure to SARS-CoV-2
20200131
897036007
Occupational exposure to Severe acute respiratory syndrome coronavirus 2 (event)
Occupational exposure to SARS-CoV-2
20210131
An exposure finding is the result of an observation or evaluation that relates to the patient's exposure to an infection. The subset below includes SNOMED CT findings relating to COVID-19 exposure.
CV19-ASS-ExposureFinding
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
870577009
At increased risk of exposure to severe acute respiratory syndrome coronavirus 2 (finding)
At increased risk of exposure to severe acute respiratory syndrome coronavirus 2
20200731
Covid-19 and Viral Co-Infections
The following organism should be used when recording the organism causing COVID-19 infections.
CV19-ASS-Organism
Concept id
Fully Specified Name
en-US Preferred Term
Effective Time
840533007
Severe acute respiratory syndrome coronavirus 2 (organism)
SARS-CoV-2
20200131
The following organisms can be used to record the cause of related viral co-infections.
CV19-ASS-ViralCoInfections
Intensional Definition:
<< 49872002 |Virus (organism)| MINUS 840533007 |Severe acute respiratory syndrome coronavirus 2 (organism)|
Footnotes
1 Articles found using the Pubmed query "https://pubmed.ncbi.nlm.nih.gov/?term=covid+19&filter=pubt.review"
2 COVID Symptom Tracker Research Updates
3 COVID-19 Case Reporting Forms, including: COVID-19 Case Report Form, CDC, US Novel Coronavirus (COVID-19) Case Record Form, Global COVID-19 Clinical Platform, World Health Organization COVID-19 Hospitalisation in England Surveillance System (CHESS) Daily Reporting, NHS, UK
4 Coronavirus: what are asymptomatic and mild COVID-19?, Patient.info Coronavirus: what are moderate, severe and critical COVID-19?, Patient.info
5 SNOMED CT Editorial Guide, SNOMED International
6 Clinical papers, including: COVID-19: Gastrointestinal Manifestations and Potential Fecal-Oral Transmission COVID-19 and the Cardiovascular System Caution on Kidney Dysfunctions of COVID-19 Patients Holistic care for patients with severe coronavirus disease 2019: An expert consensus
7 Rhabdomyolysis as Potential Late Complication Associated with COVID-19 Neurological Manifestations of Hospitalized Patients with COVID-19 in Wuhan, China: A Retrospective Case Series Study Dysregulation of Immune Response in Patients with COVID-19 in Wuhan, China
8 CHESS Daily Reporting, NHS, UK
9 COVID-19 - High Risk Shielded Patient List Identification Methodology - Clinical Inclusion Criteria, NHS, UK
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