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�。↖nfectious Diseases）.................................................................................................................57
3.9.5 遗传性疾�。℅enetic 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
5
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
6
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:
|
|
资源大�。�1.59 MB 
