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(SPIA) Terminology and Codes Requesting Pathology

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(SPIA) Terminology and Codes Requesting Pathology Standards for Pathology Informatics in Australia (SPIA) Terminology and Codes Requesting Pathology (v3.0) Superseding and incorporating the Australian Pathology Units and Terminology Standards and Guidelines (APUTS) ISBN: Pending State Health Publication Number (SHPN): Pending Online copyright © RCPA 2017 This work (Standards and Guidelines) is copyright. You may download, display, print and reproduce the Standards and Guidelines for your personal, non- commercial use or use within your organisation subject to the following terms and conditions: 1. The Standards and Guidelines may not be copied, reproduced, communicated or displayed, in whole or in part, for profit or commercial gain. 2. Any copy, reproduction or communication must include this RCPA copyright notice in full. 3. No changes may be made to the wording of the Standards and Guidelines including commentary, tables or diagrams. Excerpts from the Standards and Guidelines may be used. References and acknowledgments must be maintained in any reproduction or copy in full or part of the Standards and Guidelines. Apart from any use as permitted under the Copyright Act 1968 or as set out above, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to RCPA, 207 Albion St, Surry Hills, NSW 2010, Australia. This material contains content from LOINC® (http://loinc.org). The LOINC table, LOINC codes, LOINC panels and forms file, LOINC linguistic variants file, LOINC/RSNA Radiology Playbook, and LOINC/IEEE Medical Device Code Mapping Table are copyright © 1995-2016, Regenstrief Institute, Inc. and the Logical Observation Identifiers Names and Codes (LOINC) Committee and is available at no cost under the license at http://loinc.org/terms-of-use.” This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO®). All rights reserved. SNOMED CT was originally created by The College of American Pathologists. IHTSDO®, SNOMED® and SNOMED CT® are registered trademarks of the IHTSDO. This product includes all or a portion of the UCUM table, UCUM codes, and UCUM definitions or is derived from it, subject to a license from Regenstrief Institute, Inc. and The UCUM Organization. Your use of the UCUM table, UCUM codes, UCUM definitions also is subject to this license, a copy of which is available at http://unitsofmeasure.org. The current complete UCUM table, UCUM Specification are available for download at http://unitsofmeasure.org. The UCUM table and UCUM codes are copyright © 1995-2009, Regenstrief Institute, Inc. and the Unified Codes for Units of Measures (UCUM) Organization. All rights reserved. First published: February, 2013, 1st Edition (version 1.0) Standards for Pathology Informatics in Australia (SPIA) Previously known as the Australian Pathology Units and Terminology Standards and Guidelines (APUTS) Terminology for Requesting Pathology Copyright © 2013- 2017 RCPA. All rights reserved. This material contains information which is protected by copyright. You may download, display, print and reproduce any material for your personal, non-commercial use or use within your organisation subject to the following terms and conditions: 1. The material may not be copied, reproduced, communicated or displayed, in whole or in part, for profit or commercial gain. 2. Any copy, reproduction or communication must include this RCPA copyright notice in full. 3. No changes may be made to the wording of the Standards and Guidelines, terminology reference sets and information models including commentary, tables or diagrams. Excerpts from the Standards and Guidelines, terminology reference sets and information models may be used. References and acknowledgments must be maintained in any reproduction or copy in full or part of the material. Apart from any use as permitted under the Copyright Act 1968 or as set out above, all other rights are reserved. Requests and inquiries concerning reproduction and rights should be addressed to RCPA, 207 Albion St, Surry Hills, NSW 2010, Australia. This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO®). All rights reserved. SNOMED CT was originally created by The College of American Pathologists. IHTSDO®, SNOMED® and SNOMED CT® are registered trademarks of the IHTSDO. TRIM Document #: D156353 Document History: Version Reason for Change Author Date Michael Legg / Dr Initial Terminology for Requesting pathology, published by the RCPA Pathology Units and Terminology 1.0 Christiaan 12-Feb-13 Standardisation Project. Swanepoel 2.0 Added Document Revision History worksheet. Donna Moore 06-Jun-14 Changed the filename from "PUTS Terminology for Requesting Pathology Subset " to "APUTS Requesting Pathology terminology reference set". Added additional SNOMED codes to this list after review from WG2 from PITUS project. Added "WBC Diff; Differential" to synonyms for White cell count. 2.1 After public feedback and approval by PITUS steering committee the following changes were made: Donna Moore 06-Nov-14 - Changed preferred name to 'Thrombin time' (was 'Thrombin') . - Changed the preferred name for a number of newly added v2.0 tests, refer to those tests marked with '2.1' in the version column. 3.0 Updated and new tests added, refer to '3.0' in the 'Version' and 'History' fields for details. Donna Moore 10-Jan-16 Updated after public comments. Standards for Pathology Informatics in Australia (SPIA) Terminology for Requesting Pathology RCPA Preferred term RCPA Synonyms Usage guidance Length Specimen Terminology binding (SNOMED CT-AU) Version History 11-Deoxycortisol 16 Serum 313778009 | Serum 11-deoxycortisol measurement | 3.0 3.0 - Added by PITUS-16 project 11-Deoxycortisol urine 22 Urine 444132007 | Quantitative measurement of 11- 3.0 3.0 - Added by PITUS-16 project deoxycortisol in urine specimen | 14-3-3 protein CSF 14-3-3 protein cerebrospinal fluid; CJD 18 CSF 430551003 | Measurement of 14-3-3 protein 3.0 3.0 - Added by PITUS-16 project protein; Creutzfeldt-Jakob disease protein concentration in cerebrospinal fluid | 17-Hydroxypregnenolone 17 OH Pregnenolone 22 Serum 104447005 | 17-Hydroxypregnenolone measurement | 3.0 3.0 - Added by PITUS-16 project 17-Hydroxyprogesterone 17 OH Progesterone; 17-OHP; Hydroxy 22 Serum 41668001 | 17 Hydroxyprogesterone measurement, 2.1 2.1 - Changed preferred term from '17-Hydroxprogesterone' Progesterone serum | 2.0 - Added by PITUS-14 Working group 2 21-Hydroxylase Ab 18 Serum 117889006 | Measurement of 21-hydroxylase antibody 3.0 3.0 - Added by PITUS-16 project | 3-Hydroxy-3-methylglutarate 27 Serum 121893007 | 3-Hydroxy,3-methylglutarate 3.0 3.0 - Added by PITUS-16 project measurement | 3-Methoxytyramine 3-MT 17 Plasma 801311000168102 | Measurement of 3- 3.0 3.0 - Added by PITUS-16 project methoxytyramine in plasma specimen | 3-Methoxytyramine urine 3-MT urine 23 Urine 394952009 | Urine 3-methoxytyramine/creatinine 3.0 3.0 - Added by PITUS-16 project ratio | 3-Methoxytyramine urine 24h 3-MT 24 hr urine 27 Urine 394951002 | 24 hour urine 3-methoxytyramine output 3.0 3.0 - Changed preferred term from '3-Methoxythyramine'; Added | synonym 2.0 - Added by PITUS-14 Working group 2 4-Hydroxy-3-methoxymandelate urine 24h 3-Methyl,4-hydroxymandelate; HMMA urine 38 24 hr urine 121302000 | 3-Methyl,4-hydroxymandelate 3.0 3.0 - Added by PITUS-16 project measurement| 5HIAA urine 5 indole acetic acid 11 Urine 104741005 | 5-Hydroxyindoleacetic acid measurement 2.0 2.0 - Added by PITUS-14 Working group 2 | 5-Nucleotidase 14 Serum 2507007 | 5' Nucleotidase measurement | 3.0 3.0 - Added by PITUS-16 project Acanthamoeba culture Acanthamoeba detection 20 122192001 | Acanthamoeba species culture | 3.0 3.0 - Added by PITUS-16 project Acanthamoeba nucleic acid Acanthamoeba PCR; Acanthamoeba 25 122408004 | Acanthamoeba species identification | 3.0 3.0 - Added by PITUS-16 project detection Acetylcholine receptor Ab AChR Ab; Myasthenia gravis antibodies; 25 Serum 122224000 | Measurement of acetylcholine receptor 3.0 3.0 - Added synonym 'Myasthenia antibodies' AChR antibodies; Myasthenia antibodies antibody | 2.1 - Changed preferred term from 'Acetylcholine Receptor Ab' 2.0 - Added by PITUS-14 Working group 2 Acid fast bacilli culture AFB culture; non-tuberculous mycobacteria; 25 Urine; CSF; 117769004 | Acid fast bacteria identification | 3.0 3.0 - Added by PITUS-16 project M. ulcerans; M. abscessus; Atypical Tissue; Sputa; mycobacteria; Rapid growers Skin; Swabs; Fluids Acid fast bacilli microscopy AFB microscopy 28 Urine; CSF 391483001 | Microscopy (acid fast bacilli) | 3.0 3.0 - Added by PITUS-16 project Acid fast bacilli nucleic acid Acid fast bacilli PCR; Mycobacterium PCR; TB 30 766101000168107 | Acid fast bacilli nucleic acid assay 3.0 3.0 - Added by PITUS-16 project PCR; MAC PCR; Mycobacterium avium | complex PCR Acinetobacter sp screen Infection control screen 23 413063005 | Acinetobacter species screening test | 3.0 3.0 - Added by PITUS-16 project ACTH Adrenocorticotropic hormone 4 Serum 49466006 | Adrenocorticotropic hormone 2.0 2.0 - Added by PITUS-14 Working group 2 measurement | Activated clotting time ACT; Activated coagulation time 23 69874005 | Coagulation time, activated | 3.0 3.0 - Added by PITUS-16 project Active vitamin B12 Holotranscobalamin; Active B12 18 Serum 439568007 | Measurement of holotranscobalamin 3.0 3.0 - Added synonym 'Active B12' concentration | 1.0 -
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