目錄（Table of Contents）
版權聲明與許可協議（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 字母不區分大小寫（Case insensitivity）........................................................................................................25
2.1.5 羅馬數字與阿拉伯數字（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（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 放射醫學報告（RADIOLOGY REPORTS）...............................................................................................................65
4.3.1 診斷性放射醫學報告（Diagnostic Radiology Reports）.........................................................................66
4.3.2 介入性放射醫學報告（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 采用多個組件創建臨床記錄的規則（RULES FOR CREATING CLINICAL NOTES FROM MULTIPLE COMPONENTS）........74
7.5 工作展望（FUTURE WORK）..................................................................................................................................75
8 醫囑組（ORDER PANELS／BATTERIES）...........................................................................................................81
8.1 目的（GOALS）.......................................................................................................................................................82
8.2 級聯試驗（REFLEX TESTS，追加試驗）................................................................................................................83
8.3 計算或衍生結果（CALCULATED OR DERIVED RESULTS）.....................................................................................83
8.4 關聯觀測指標（ASSOCIATED OBSERVATIONS）.....................................................................................................83
8.5 醫囑組的LOINC命名規則（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數據庫結構（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數據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）名稱中允許出現的縮略語（Table 2: Allowable Abbreviations in Component (analyte) Names）...................23
表3. 字母大小寫規則（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數據庫字段名（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數據庫報告中的表格列（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®數據庫、LOINC®數據庫表和相關文件及《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®數據庫（但除外其中所包含的適用于上述版權的LOINC®代碼、LOINC®數據庫表和相關文件）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:
|
|
資源大小：1.59 MB 
