观测指标标识符逻辑命名与编码系统LOINC用户指南中文版

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观测指标标识符逻辑命名与编码系统LOINC用户指南中文版
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目录(Table of Contents)
版权声明与许可协议(COPYRIGHT NOTICE AND LICENSE).............................................................................6
前言与简介(PREFACE AND INTRODUCTION)...................................................................................................12
致谢(ACKNOWLEDGMENTS)................................................................................................................................17
1 目标(GOALS)...........................................................................................................................................................18
1.1 成功应用(SUCCESSES)........................................................................................................................................19
1.2 不属于LOINC名称组成部分的内容(WHAT IS NOT PART OF THE NAME)........................................................20
1.3 本指南的适用范围(SCOPE OF THIS DOCUMENT)................................................................................................21
2 试验/观测指标名称的主要组成部分(MAJOR "PARTS" OF A TEST/OBSERVATION NAME)..................22
2.1 一般命名规则(GENERAL NAMING CONVENTIONS).............................................................................................23
2.1.1 成分/分析物名称中的缩略语(Abbreviations in names of component/analyte).........................................23
2.1.2 全称中成分(分析物)部分的一般命名规则[General naming rules for the component (analyte) part of the fully specified name]...23
2.1.3 分析物名称中的标点符号(Punctuation in analyte names).........................................................................25
2.1.4 字母不区分大小写(Case insensitivity)........................................................................................................25
2.1.5 罗马数字与阿拉伯数字(Roman numerals vs. Arabic numerals)................................................................25
2.2 成分/分析物(第一部分)[COMPONENT/ANALYTE (1ST PART)]......................................................................25
2.2.1 分析物名称(第一子块)[Analyte Name (1st subpart)]............................................................................26
2.2.2 刺激试验(第二子块)[Challenge test (2nd subpart)]...............................................................................26
2.3 属性类型(又称量值类型)(第二部分)[KIND OF PROPERTY (ALSO CALLED KIND OF QUANTITY) (2ND PART)]..32
2.4 时间特征(时刻与时间间隔)(第三部分)[TIME ASPECT (POINT OR MOMENT IN TIME VS. TIME INTERVAL) (3RD PART)]35
2.4.1 时间特征的修饰成分(Time Aspect Modifier)............................................................................................37
2.5 体系(样本)类型(第四部分)[SYSTEM (SAMPLE) TYPE (4TH PART)]........................................................37
2.5.1 超体系(第二子块)[Super system (2nd subpart)]....................................................................................39
2.6 标尺类型(第五部分)[TYPE OF SCALE (5TH PART)].......................................................................................41
2.7 方法类型(第六部分)[TYPE OF METHOD (6TH PART)]...................................................................................42
2.7.1 DNA/RNA探针/指标(DNA/RNA probes/measures)..................................................................................43
2.7.2 免疫荧光(IF)[Immune fluorescence (IF)]...............................................................................................44
2.7.3 免疫染色(Immune Stain).............................................................................................................................44
2.7.4 酶免疫分析(EIA)[Enzyme Immune Assay (EIA)].................................................................................44
2.7.5 凝血功能试验(Coagulation)........................................................................................................................44
2.7.6 染色试验检查(Stains)..................................................................................................................................44
2.7.7 临床指标(Clinical measures).......................................................................................................................44
2.7.8 成像检查(Imaging studies)...........................................................................................................................45
2.8 短小实用的简称(SHORT CONVENIENT NAMES)..................................................................................................45
3 特殊情况(SPECIAL CASES)..................................................................................................................................45
3.1 被看作变量或数值的结果(FINDINGS VIEWED AS VARIABLES OR AS VALUES)..................................................45
3.1.1 结果取值(Value)..........................................................................................................................................45
3.1.2 可变性或多项选择性结果的标识方法[Variable (Multiple Choice) Approach]........................................46
3.2 血库(BLOOD BANK).............................................................................................................................................46
3.3 免疫活性检查(流式细胞仪)[IMMUNOCOMPETENCE STUDIES (FLOW CYTOMETRY)]...................................47
3.4 微生物学结果的一般处理方法(GENERAL APPROACH TO MICROBIOLOGY RESULTS).......................................48
3.5 抗生素敏感性试验(ANTIMICROBIAL SUSCEPTIBILITIES)...................................................................................50
3.6 细胞计数(CELL COUNTS)....................................................................................................................................50
3.7 皮肤试验(SKIN TESTS)........................................................................................................................................51
3.8 毒理学—药物滥用的筛查与确认(TOXICOLOGY – DRUG OF ABUSE SCREENING AND CONFIRMATION).........51
3.8.1 药物的毒理学分组(Toxicology drug groups).............................................................................................52
3.8.2 判断界值(Cutoffs)........................................................................................................................................53
LOINC Users’ Guide translated to Simplified Chinese —June 1, 2005
4
3.8.3 筛查与确认方法的报告(Reporting the method used for screen and confirm)............................................53
3.8.4 具体药物/代谢物的检测结果(Individual drug/metabolite test results)......................................................54
3.8.5 命名问题(Naming issues).............................................................................................................................54
3.8.6 小结(Summary)............................................................................................................................................54
3.9 分子遗传学方面的LOINC命名(MOLECULAR GENETICS LOINC NAMING)...................................................55
3.9.1 引言(Introduction)........................................................................................................................................55
3.9.2 术语学(Terminology)...................................................................................................................................55
3.9.3 分子遗传学一般命名规则(General Molecular genetic naming rules)........................................................56
3.9.4 传染性疾病(Infectious Diseases).................................................................................................................57
3.9.5 遗传性疾病(Genetic Diseases).....................................................................................................................57
3.9.6 三核苷酸重复序列(Trinucleotide repeats)..................................................................................................59
3.9.7 血液病理学基因重组(Hematopathology gene re-arrangement).................................................................59
3.9.8 基因易位(Translocations)............................................................................................................................60
3.9.9 身份测试(Identity testing)............................................................................................................................60
3.9.10 肿瘤相关的肿瘤遗传学(Tumor Relation Tumor Genetics)......................................................................61
3.10 变态反应的检测(ALLERGY TESTING)..............................................................................................................62
4 临床观测指标(CLINICAL OBSERVATIONS AND MEASURES)....................................................................62
4.1 引言(INTRODUCTION)..........................................................................................................................................63
4.2 原子型与分子型(前组合式命名)[ATOMIC VERSUS MOLECULAR (PRE-COORDINATED NAMES)]..........................................65
4.3 放射医学报告(RADIOLOGY REPORTS)...............................................................................................................65
4.3.1 诊断性放射医学报告(Diagnostic Radiology Reports).........................................................................66
4.3.2 介入性放射医学报告(Interventional Radiology Reports)..........................................................................69
5 肿瘤登记(TUMOR REGISTRY)............................................................................................................................70
6 索赔信息附件(CLAIMS ATTACHMENTS).........................................................................................................70
7 HL7 LOINC文档类型词表域(HL7 LOINC DOCUMENT TYPE VOCABULARY DOMAIN).....................70
7.1 文档类型代码在HL7消息中的使用(USE OF DOCUMENT TYPE CODES IN HL7 MESSAGES)............................70
7.2 与其它术语的关系(RELATIONSHIP WITH OTHER TERMINOLOGIES)...................................................................71
7.3 文档类型组件(DOCUMENT TYPE COMPONENTS)...............................................................................................71
7.4 采用多个组件创建临床记录的规则(RULES FOR CREATING CLINICAL NOTES FROM MULTIPLE COMPONENTS)........74
7.5 工作展望(FUTURE WORK)..................................................................................................................................75
8 医嘱组(ORDER PANELS/BATTERIES)...........................................................................................................81
8.1 目的(GOALS).......................................................................................................................................................82
8.2 级联试验(REFLEX TESTS,追加试验)................................................................................................................83
8.3 计算或衍生结果(CALCULATED OR DERIVED RESULTS).....................................................................................83
8.4 关联观测指标(ASSOCIATED OBSERVATIONS).....................................................................................................83
8.5 医嘱组的LOINC命名规则(LOINC RULES FOR REPRESENTING ORDER PANEL NAMES)..................................83
9 标准化调查问卷(STANDARDIZED SURVEY INSTRUMENTS)......................................................................85
附录(APPENDICES)...................................................................................................................................................86
附录A—LOINC数据库结构(APPENDIX A - LOINC DATABASE STRUCTURE).......................................86
附录B—类(APPENDIX B – CLASSES).............................................................................................................90
附录C—MOD 10模校验位的计算方法(APPENDIX C - CALCULATING MOD 10 CHECK DIGITS)........93
附录D—向LOINC数据库提交新增或变更记录的方法与步骤(APPENDIX D - PROCEDURE FOR SUBMITTING ADDITIONS/CHANGES TO THE DATABASE)..................................94
附录E—有关LOINC打印报告的说明(APPENDIX E - LOINC PRINTED REPORT DESCRIPTION)......116
附录F—LOINC属性匹配示例(APPENDIX F - EXAMPLES FOR LOINC PROPERTY MATCHING)......117
附录G—LOINC委员会成员名单(APPENDIX G - LOINC COMMITTEE MEMBERS)..............................122
参考文献(LITERATURE CITED)..........................................................................................................................124
LOINC Users’ Guide translated to Simplified Chinese —June 1, 2005
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表(Tables)
表1. 分析物全称的层级结构(Table 1: Hierarchical Structure of Fully Specified Analyte Names)...................................................22
表2. 成分(分析物)名称中允许出现的缩略语(Table 2: Allowable Abbreviations in Component (analyte) Names)...................23
表3. 字母大小写规则(Table 3: Case Specifying Conventions)..........................................................................................................25
表4. 刺激后的时间延迟(Table 4: Time Delay Post Challenge).........................................................................................................27
表5. 刺激部分中的途径缩略语(Table 5: Route Abbreviations for Challenge Part)..........................................................................28
表6. 刺激的性质(Table 6: Nature of Challenge).................................................................................................................................29
表7. 属性类型(Table 7: Kind of Property)..........................................................................................................................................33
表8. 持续时间的类别(Table 8: Duration Categories).........................................................................................................................35
表9. 时间特征修饰成分的代码(Table 9: Time Aspect Modifier Codes)...........................................................................................37
表10. 实验室试验项目的体系/样本类型代码(Table 10: Laboratory System/Sample Type Codes).................................................38
表11. 超体系(Table 11: Super System)...............................................................................................................................................39
表12. 标尺类型(Table 12: Type of Scale)...........................................................................................................................................41
表13. 试验方法缩略语(Table 13: Method Abbreviations).................................................................................................................42
表14A. 分类为DNA/RNA靶向扩增方法的特异性方法举例(Table 14A: Examples of specific methods that would be classes as target amplified DNA/RNA methods).........................................................43
表14B. LOINC中被定义为信号放大方法的特异性方法举例(Table 14B. Examples of specific methods that would be defined in LOINC as signal amplification methods)..............................44
表15. 培养结果举例(Table 15. Example Culture Results).................................................................................................................49
表16. 药物敏感性试验方法(Table 16: Drug Susceptibility Methods)...............................................................................................50
表17. 标识遗传基因缺陷位置的三种命名方法(Table 17. Three types of nomenclatures for identifying the location of a genetic defect).............................................56
表18. 单字母氨基酸代码列表(Table 18. List of single letter amino acid codes)...............................................................................56
表19. 迄今临床LOINC部分所涵盖的主题(Table 19. Subjects covered to date in clinical LOINC)...............................................64
表20. 类(Table 20: Classes).................................................................................................................................................................90
表21. 提交文件示例(Table 21: Example submission)........................................................................................................................95
表22a. 提交文件中的Access数据库字段名(Table 22a Access Field Names for Submissions).......................................................95
表22b. 供Regenstrief填写的内容(提交时需保持空值的字段)[Table 22b Content Added by Regenstrief (Fields left blank in submission)]..................................96
表23. 可打印型LOINC数据库报告中的表格列(Table 23: Columns Appearing on Printed Reports)...................................................116
LOINC Users’ Guide translated to Simplified Chinese —June 1, 2005
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版权声明与许可协议(Copyright Notice and License)
The LOINC® codes, LOINC® database, LOINC® table and related files, and LOINC® Users' Guide are copyright © 1995-2005, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee. All rights reserved.
LOINC®代码、LOINC®数据库、LOINC®数据库表和相关文件及《LOINC®用户指南》版权所有© 1995-2005 Regenstrief Institute, Inc.(Regenstrief研究院股份有限公司)及Logical Observation Identifiers Names and Codes (LOINC) Committee(观测指标标识符逻辑命名与编码系统委员会,LOINC委员会)。保留所有权利。
The RELMA® program, RELMA® database (but excluding LOINC® codes, and LOINC® table and related files incorporated therein, which are subject to the copyright above) and RELMA® Users' Manual are copyright © 1995-2005, Regenstrief Institute, Inc. All rights reserved.
RELMA®程序、RELMA®数据库(但除外其中所包含的适用于上述版权的LOINC®代码、LOINC®数据库表和相关文件)及《RELMA®用户手册》版权所有© 1995-2005 Regenstrief Institute, Inc.(Regenstrief研究院股份有限公司)。保留所有权利。
LOINC® and RELMA® are registered United States trademarks of Regenstrief Institute, Inc.
LOINC®和RELMA®属于Regenstrief Institute, Inc.的美国注册商标。
Permission is hereby granted in perpetuity, without payment of license fees or royalties, to use, copy, or distribute the RELMA® program, RELMA® Users' Manual, RELMA® database, LOINC® codes, LOINC® Users' Guide, LOINC® database, and LOINC® table and related files for any commercial or non-commercial purpose, subject to the following terms and conditions:
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