目錄(Table of Contents)
版權(quán)聲明與許可協(xié)議(COPYRIGHT NOTICE AND LICENSE).............................................................................6
前言與簡介(PREFACE AND INTRODUCTION)...................................................................................................12
致謝(ACKNOWLEDGMENTS)................................................................................................................................17
1 目標(GOALS)...........................................................................................................................................................18
1.1 成功應(yīng)用(SUCCESSES)........................................................................................................................................19
1.2 不屬于LOINC名稱組成部分的內(nèi)容(WHAT IS NOT PART OF THE NAME)........................................................20
1.3 本指南的適用范圍(SCOPE OF THIS DOCUMENT)................................................................................................21
2 試驗/觀測指標名稱的主要組成部分(MAJOR "PARTS" OF A TEST/OBSERVATION NAME)..................22
2.1 一般命名規(guī)則(GENERAL NAMING CONVENTIONS).............................................................................................23
2.1.1 成分/分析物名稱中的縮略語(Abbreviations in names of component/analyte).........................................23
2.1.2 全稱中成分(分析物)部分的一般命名規(guī)則[General naming rules for the component (analyte) part of the fully specified name]...23
2.1.3 分析物名稱中的標點符號(Punctuation in analyte names).........................................................................25
2.1.4 字母不區(qū)分大小寫(Case insensitivity)........................................................................................................25
2.1.5 羅馬數(shù)字與阿拉伯數(shù)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 分析物名稱(第一子塊)[Analyte Name (1st subpart)]............................................................................26
2.2.2 刺激試驗(第二子塊)[Challenge test (2nd subpart)]...............................................................................26
2.3 屬性類型(又稱量值類型)(第二部分)[KIND OF PROPERTY (ALSO CALLED KIND OF QUANTITY) (2ND PART)]..32
2.4 時間特征(時刻與時間間隔)(第三部分)[TIME ASPECT (POINT OR MOMENT IN TIME VS. TIME INTERVAL) (3RD PART)]35
2.4.1 時間特征的修飾成分(Time Aspect Modifier)............................................................................................37
2.5 體系(樣本)類型(第四部分)[SYSTEM (SAMPLE) TYPE (4TH PART)]........................................................37
2.5.1 超體系(第二子塊)[Super system (2nd subpart)]....................................................................................39
2.6 標尺類型(第五部分)[TYPE OF SCALE (5TH PART)].......................................................................................41
2.7 方法類型(第六部分)[TYPE OF METHOD (6TH PART)]...................................................................................42
2.7.1 DNA/RNA探針/指標(DNA/RNA probes/measures)..................................................................................43
2.7.2 免疫熒光(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 凝血功能試驗(Coagulation)........................................................................................................................44
2.7.6 染色試驗檢查(Stains)..................................................................................................................................44
2.7.7 臨床指標(Clinical measures).......................................................................................................................44
2.7.8 成像檢查(Imaging studies)...........................................................................................................................45
2.8 短小實用的簡稱(SHORT CONVENIENT NAMES)..................................................................................................45
3 特殊情況(SPECIAL CASES)..................................................................................................................................45
3.1 被看作變量或數(shù)值的結(jié)果(FINDINGS VIEWED AS VARIABLES OR AS VALUES)..................................................45
3.1.1 結(jié)果取值(Value)..........................................................................................................................................45
3.1.2 可變性或多項選擇性結(jié)果的標識方法[Variable (Multiple Choice) Approach]........................................46
3.2 血庫(BLOOD BANK).............................................................................................................................................46
3.3 免疫活性檢查(流式細胞儀)[IMMUNOCOMPETENCE STUDIES (FLOW CYTOMETRY)]...................................47
3.4 微生物學(xué)結(jié)果的一般處理方法(GENERAL APPROACH TO MICROBIOLOGY RESULTS).......................................48
3.5 抗生素敏感性試驗(ANTIMICROBIAL SUSCEPTIBILITIES)...................................................................................50
3.6 細胞計數(shù)(CELL COUNTS)....................................................................................................................................50
3.7 皮膚試驗(SKIN TESTS)........................................................................................................................................51
3.8 毒理學(xué)—藥物濫用的篩查與確認(TOXICOLOGY – DRUG OF ABUSE SCREENING AND CONFIRMATION).........51
3.8.1 藥物的毒理學(xué)分組(Toxicology drug groups).............................................................................................52
3.8.2 判斷界值(Cutoffs)........................................................................................................................................53
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3.8.3 篩查與確認方法的報告(Reporting the method used for screen and confirm)............................................53
3.8.4 具體藥物/代謝物的檢測結(jié)果(Individual drug/metabolite test results)......................................................54
3.8.5 命名問題(Naming issues).............................................................................................................................54
3.8.6 小結(jié)(Summary)............................................................................................................................................54
3.9 分子遺傳學(xué)方面的LOINC命名(MOLECULAR GENETICS LOINC NAMING)...................................................55
3.9.1 引言(Introduction)........................................................................................................................................55
3.9.2 術(shù)語學(xué)(Terminology)...................................................................................................................................55
3.9.3 分子遺傳學(xué)一般命名規(guī)則(General Molecular genetic naming rules)........................................................56
3.9.4 傳染性疾。↖nfectious Diseases).................................................................................................................57
3.9.5 遺傳性疾。℅enetic Diseases).....................................................................................................................57
3.9.6 三核苷酸重復(fù)序列(Trinucleotide repeats)..................................................................................................59
3.9.7 血液病理學(xué)基因重組(Hematopathology gene re-arrangement).................................................................59
3.9.8 基因易位(Translocations)............................................................................................................................60
3.9.9 身份測試(Identity testing)............................................................................................................................60
3.9.10 腫瘤相關(guān)的腫瘤遺傳學(xué)(Tumor Relation Tumor Genetics)......................................................................61
3.10 變態(tài)反應(yīng)的檢測(ALLERGY TESTING)..............................................................................................................62
4 臨床觀測指標(CLINICAL OBSERVATIONS AND MEASURES)....................................................................62
4.1 引言(INTRODUCTION)..........................................................................................................................................63
4.2 原子型與分子型(前組合式命名)[ATOMIC VERSUS MOLECULAR (PRE-COORDINATED NAMES)]..........................................65
4.3 放射醫(yī)學(xué)報告(RADIOLOGY REPORTS)...............................................................................................................65
4.3.1 診斷性放射醫(yī)學(xué)報告(Diagnostic Radiology Reports).........................................................................66
4.3.2 介入性放射醫(yī)學(xué)報告(Interventional Radiology Reports)..........................................................................69
5 腫瘤登記(TUMOR REGISTRY)............................................................................................................................70
6 索賠信息附件(CLAIMS ATTACHMENTS).........................................................................................................70
7 HL7 LOINC文檔類型詞表域(HL7 LOINC DOCUMENT TYPE VOCABULARY DOMAIN).....................70
7.1 文檔類型代碼在HL7消息中的使用(USE OF DOCUMENT TYPE CODES IN HL7 MESSAGES)............................70
7.2 與其它術(shù)語的關(guān)系(RELATIONSHIP WITH OTHER TERMINOLOGIES)...................................................................71
7.3 文檔類型組件(DOCUMENT TYPE COMPONENTS)...............................................................................................71
7.4 采用多個組件創(chuàng)建臨床記錄的規(guī)則(RULES FOR CREATING CLINICAL NOTES FROM MULTIPLE COMPONENTS)........74
7.5 工作展望(FUTURE WORK)..................................................................................................................................75
8 醫(yī)囑組(ORDER PANELS/BATTERIES)...........................................................................................................81
8.1 目的(GOALS).......................................................................................................................................................82
8.2 級聯(lián)試驗(REFLEX TESTS,追加試驗)................................................................................................................83
8.3 計算或衍生結(jié)果(CALCULATED OR DERIVED RESULTS).....................................................................................83
8.4 關(guān)聯(lián)觀測指標(ASSOCIATED OBSERVATIONS).....................................................................................................83
8.5 醫(yī)囑組的LOINC命名規(guī)則(LOINC RULES FOR REPRESENTING ORDER PANEL NAMES)..................................83
9 標準化調(diào)查問卷(STANDARDIZED SURVEY INSTRUMENTS)......................................................................85
附錄(APPENDICES)...................................................................................................................................................86
附錄A—LOINC數(shù)據(jù)庫結(jié)構(gòu)(APPENDIX A - LOINC DATABASE STRUCTURE).......................................86
附錄B—類(APPENDIX B – CLASSES).............................................................................................................90
附錄C—MOD 10模校驗位的計算方法(APPENDIX C - CALCULATING MOD 10 CHECK DIGITS)........93
附錄D—向LOINC數(shù)據(jù)庫提交新增或變更記錄的方法與步驟(APPENDIX D - PROCEDURE FOR SUBMITTING ADDITIONS/CHANGES TO THE DATABASE)..................................94
附錄E—有關(guān)LOINC打印報告的說明(APPENDIX E - LOINC PRINTED REPORT DESCRIPTION)......116
附錄F—LOINC屬性匹配示例(APPENDIX F - EXAMPLES FOR LOINC PROPERTY MATCHING)......117
附錄G—LOINC委員會成員名單(APPENDIX G - LOINC COMMITTEE MEMBERS)..............................122
參考文獻(LITERATURE CITED)..........................................................................................................................124
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表(Tables)
表1. 分析物全稱的層級結(jié)構(gòu)(Table 1: Hierarchical Structure of Fully Specified Analyte Names)...................................................22
表2. 成分(分析物)名稱中允許出現(xiàn)的縮略語(Table 2: Allowable Abbreviations in Component (analyte) Names)...................23
表3. 字母大小寫規(guī)則(Table 3: Case Specifying Conventions)..........................................................................................................25
表4. 刺激后的時間延遲(Table 4: Time Delay Post Challenge).........................................................................................................27
表5. 刺激部分中的途徑縮略語(Table 5: Route Abbreviations for Challenge Part)..........................................................................28
表6. 刺激的性質(zhì)(Table 6: Nature of Challenge).................................................................................................................................29
表7. 屬性類型(Table 7: Kind of Property)..........................................................................................................................................33
表8. 持續(xù)時間的類別(Table 8: Duration Categories).........................................................................................................................35
表9. 時間特征修飾成分的代碼(Table 9: Time Aspect Modifier Codes)...........................................................................................37
表10. 實驗室試驗項目的體系/樣本類型代碼(Table 10: Laboratory System/Sample Type Codes).................................................38
表11. 超體系(Table 11: Super System)...............................................................................................................................................39
表12. 標尺類型(Table 12: Type of Scale)...........................................................................................................................................41
表13. 試驗方法縮略語(Table 13: Method Abbreviations).................................................................................................................42
表14A. 分類為DNA/RNA靶向擴增方法的特異性方法舉例(Table 14A: Examples of specific methods that would be classes as target amplified DNA/RNA methods).........................................................43
表14B. LOINC中被定義為信號放大方法的特異性方法舉例(Table 14B. Examples of specific methods that would be defined in LOINC as signal amplification methods)..............................44
表15. 培養(yǎng)結(jié)果舉例(Table 15. Example Culture Results).................................................................................................................49
表16. 藥物敏感性試驗方法(Table 16: Drug Susceptibility Methods)...............................................................................................50
表17. 標識遺傳基因缺陷位置的三種命名方法(Table 17. Three types of nomenclatures for identifying the location of a genetic defect).............................................56
表18. 單字母氨基酸代碼列表(Table 18. List of single letter amino acid codes)...............................................................................56
表19. 迄今臨床LOINC部分所涵蓋的主題(Table 19. Subjects covered to date in clinical LOINC)...............................................64
表20. 類(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數(shù)據(jù)庫字段名(Table 22a Access Field Names for Submissions).......................................................95
表22b. 供Regenstrief填寫的內(nèi)容(提交時需保持空值的字段)[Table 22b Content Added by Regenstrief (Fields left blank in submission)]..................................96
表23. 可打印型LOINC數(shù)據(jù)庫報告中的表格列(Table 23: Columns Appearing on Printed Reports)...................................................116
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版權(quán)聲明與許可協(xié)議(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®代碼、LOINC®數(shù)據(jù)庫、LOINC®數(shù)據(jù)庫表和相關(guān)文件及《LOINC®用戶指南》版權(quán)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(觀測指標標識符邏輯命名與編碼系統(tǒng)委員會,LOINC委員會)。保留所有權(quán)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®數(shù)據(jù)庫(但除外其中所包含的適用于上述版權(quán)的LOINC®代碼、LOINC®數(shù)據(jù)庫表和相關(guān)文件)及《RELMA®用戶手冊》版權(quán)所有© 1995-2005 Regenstrief Institute, Inc.(Regenstrief研究院股份有限公司)。保留所有權(quán)利。
LOINC® and RELMA® are registered United States trademarks of Regenstrief Institute, Inc.
LOINC®和RELMA®屬于Regenstrief Institute, Inc.的美國注冊商標。
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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