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    觀測指標標識符邏輯命名與編碼系統(tǒng)LOINC用戶指南中文版
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    資源介紹
    目錄(Table of Contents)
    版權聲明與許可協(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 成功應用(SUCCESSES)........................................................................................................................................19
    1.2 不屬于LOINC名稱組成部分的內容(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)值的結果(FINDINGS VIEWED AS VARIABLES OR AS VALUES)..................................................45
    3.1.1 結果取值(Value)..........................................................................................................................................45
    3.1.2 可變性或多項選擇性結果的標識方法[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 微生物學結果的一般處理方法(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—藥物濫用的篩查與確認(TOXICOLOGY – DRUG OF ABUSE SCREENING AND CONFIRMATION).........51
    3.8.1 藥物的毒理學分組(Toxicology drug groups).............................................................................................52
    3.8.2 判斷界值(Cutoffs)........................................................................................................................................53
    LOINC Users’ Guide translated to Simplified Chinese —June 1, 2005
    4
    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/代謝物的檢測結果(Individual drug/metabolite test results)......................................................54
    3.8.5 命名問題(Naming issues).............................................................................................................................54
    3.8.6 小結(Summary)............................................................................................................................................54
    3.9 分子遺傳學方面的LOINC命名(MOLECULAR GENETICS LOINC NAMING)...................................................55
    3.9.1 引言(Introduction)........................................................................................................................................55
    3.9.2 術語學(Terminology)...................................................................................................................................55
    3.9.3 分子遺傳學一般命名規(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 三核苷酸重復序列(Trinucleotide repeats)..................................................................................................59
    3.9.7 血液病理學基因重組(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 腫瘤相關的腫瘤遺傳學(Tumor Relation Tumor Genetics)......................................................................61
    3.10 變態(tài)反應的檢測(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)學報告(RADIOLOGY REPORTS)...............................................................................................................65
    4.3.1 診斷性放射醫(yī)學報告(Diagnostic Radiology Reports).........................................................................66
    4.3.2 介入性放射醫(yī)學報告(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 與其它術語的關系(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 計算或衍生結果(CALCULATED OR DERIVED RESULTS).....................................................................................83
    8.4 關聯(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 標準化調查問卷(STANDARDIZED SURVEY INSTRUMENTS)......................................................................85
    附錄(APPENDICES)...................................................................................................................................................86
    附錄A—LOINC數(shù)據(jù)庫結構(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
    LOINC Users’ Guide translated to Simplified Chinese —June 1, 2005
    5
    表(Tables)
    表1. 分析物全稱的層級結構(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(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
    LOINC Users’ Guide translated to Simplified Chinese —June 1, 2005
    6
    版權聲明與許可協(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)庫表和相關文件及《LOINC®用戶指南》版權所有© 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的LOINC®代碼、LOINC®數(shù)據(jù)庫表和相關文件)及《RELMA®用戶手冊》版權所有© 1995-2005 Regenstrief Institute, Inc.(Regenstrief研究院股份有限公司)。保留所有權利。
    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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