Patients often have difficultly getting problems caused by medications properly recorded in their medical record, particularly post-treatment issues that have continued after stopping the medication.
Healthcare record pro forma
The idea of this pro forma came about because two new codes were introduced to the SNOMED database in 2024:
- SCTID: 1340196008 Post-SSRI sexual dysfunction
- SCTID: 1285639002 Protracted antidepressant withdrawal syndrome
SNOMED is an international list of terminology used in electronic healthcare records. The introduction of these codes helps to establish the reality of these conditions and potentially makes it possible to have them more formally recorded in your medical notes.
We know it can be daunting facing a doctor when it comes to medication-related issues. Hopefully, this form will make the process a little easier for you.
One of our contributors, Harriet, provided the idea and helped us to develop it.
How does it work?
Download the pro forma PDF at the bottom of this page.
Complete your details either by printing it out and writing on it or, depending on your browser, you may be able to add text directly onto the form and save it.
Give the form to your doctor, or if you prefer to avoid a face to face meeting, you could perhaps post or email it.
What code should I list?
Ideally, you should only list one SNOMED code for the main diagnosis that you want recording. An exception would be if you have other problems in addition to PSSD. In that case, you could perhaps list both PSSD and protracted antidepressant withdrawal syndrome.
What about MedDRA?
The Medical Dictionary for Regulatory Activities (MedDRA) is used by drug regulators to record adverse events linked to medications. There is a MedDRA code for PSSD that you could list as well:
Your doctor won’t be able to use it in your medical record, but it may further establish the validity of your problem, and adding it to the pro forma might be useful later. There isn’t a code for protracted antidepressant withdrawal syndrome.
Can I look up codes myself?
Yes. If your problem isn’t related to the issues mentioned above, or if you’re just interested to see what codes are available, you can search the databases yourself. Please note that they don’t work well on small mobile devices.
Perhaps the best place to start is the SNOMED International Edition 2024-12-01.
When the license agreement appears on screen, you’ll need to select the green “Accept” button.
Example: Typing “PSSD” or “protracted antidepressant withdrawal syndrome” into the search box on the left brings up the text below it. Clicking on this brings the code and concept details into view on the right-hand side in the blue box.
You can also access all SNOMED editions including local extensions for different countries and externally hosted extensions. For example, there is a version hosted by the National Health Service in the UK – the NHS Digital SNOMED CT Browser.
The important point about the two new SNOMED codes is that they are medication-induced conditions. While SNOMED contains many symptoms and conditions, some of which might apply to you, there may be little point in asking your doctor to record them because they wouldn’t indicate that they were caused by medication. However, there are a small number of medication-induced codes that might be useful to some patients such as:
- SCTID: 292669009 Isotretinoin adverse reaction – a drug used in the treatment of acne
- SCTID: 293228002 Finasteride adverse reaction – a drug prescribed to young men to treat baldness
- SCTID: 230333002 Akathisia caused by drug – a serious emotional side effect that can lead to suicide
There are several more “drug-induced” codes, and we are working on putting a list together.
The MedDRA browser works in a similar way. You type in the search box on the left, and it brings up the details on the right. It doesn’t recognise the abbreviation “PSSD”, so you would need to search for “post-SSRI sexual dysfunction”.
Tell us about your experience
We would like you to contact us to tell us about your experience of using this pro forma ie. what condition did you ask to have recorded and what was the response from your doctor? We also welcome any suggestions for improvement.