PCS Clinical Audit Tool – User Guide
Contents
1. 20 March 2014 PAGE 22 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Antithrombotics ALL Antithrombotics Generic Names Anticoagulants the parent category Included in Subcategories provided in CAT contains a broader set of Dabigatran etexilate medications than the set of Warfarin Sodium subcategories provided Others Apixaban Bivalirudin Rivaroxaban Generic Names Antiplatelets Included in Subcategories provided in CAT Aspirin Aspirin Glycine Dipyridamole Aspirin Clopidogrel Clopidogrel Aspirin Clopidogrel Hydrogen Sulfate Others Abciximab Dipyridamole Eptifibatide Prasugrel Ticlopidine Ticagrelo Tirofiban Aspirin Generic names Aspirin Aspirin Glycine Dipyridamole Aspirin Warfarin Generic names Warfarin Sodium Clopidogrel Generic names Clopidogrel Clopidogrel Aspirin Clopidogrel Hydrogen Sulfate 20 March 2014 PAGE 23 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Dabigatran Generic Names Dabigatran etexilate Beta Blockers Beta Blockers Antihypertensive Generic names Atenolol Bisoprolol fumarate Carvedilol Labetalol Hydrochloride Metoprolol Succinate Metoprolol Tartrate Oxprenolol Hydrochloride Pindolol Propranolol Hydrochloride Beta Blockers Chronic heart failure2. 1 ortae ross on Ert cea o ea yr DE Eo en e AAA 6 APPENDIX C BEST PRACTICE DATA CATEGORY MAPPINGS eee EE eese ee eene eene KEE nennen nnn nsns net sss KEE ERR EEE nnn 7 APPENDIX C 1 CONDITIONS DATA CATEGORY MAPPINGS BP esses nennen nennen nnne neni nnn 7 APPENDIX C T l S PREGNANCY EE 19 APPENDIX C 1 11 SCREENING EXCLUSION CONDITIONS sisisi eese enne nennen nennen AK RAN nF iNi KEN REEERE Ni 20 APPENDIX C 2 MEDICATIONS DATA CATEGORY MAPPINGS DPI 22 Medications Hed p S Medications Respiratory Medications ONE atada Ee ee APPENDIX e BT IT le EE 35 APPENDIX C 3 GENERAL DATA CATEGORY MAPPINGS BP 2 s0sesscsccecesceecsesessnsenseeesesecscessseeesneensaeesesesssesseneenes 37 APPENDIX C 4 DIABETES SIP DATA CATEGORY MAPPINGS ID 43 APPENDIX C 5 ASSIGNED PROVIDERS BP 22 2 0 3 naaa Tot cita Awa APPENDIX C 6 PATHOLOGY MAPPINGS BP 20 March 2014 PAGE 5 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 INTRODUCTION Clinical Audit Tool CAT The Clinical Audit Tool CAT analyses clinical information from GP Clinical Desktop Systems It translates data into real statistical and graphical information that is easy to understand and action This allows practitioners to assess and improve the quality and completeness of patient information The benefit to the practice is to ass
3. Irregular Smoker This option is not captured in Best Practice Ex Smoker Smoker Ex Smoker is selected Never Smoked Smoker Never smoked is selected Nothing Recorded Smoker has nothing selected Review Date This will be the date something in the Family amp Social History section is changed It is not possible to isolate Smoking changes Alcohol Drinker Best Practice Mapping Main Patient screen gt Open gt Alcohol and Smoking History gt Alcohol Freguency days a week patient usually drinks alcohol Frequency any except Never Non Drinker Frequency Never Nothing Recorded Alcohol tab has nothing selected Review Date This will be the date something in the Family amp Social History section is changed It is not possible to isolate Alcohol changes PAGE 38 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 20 March 2014 Measurements Best Practice Mapping Pathology BMI Patient Record gt Main Patient Screen gt Observations screen Waist Patient Record gt Main Patient Screen gt Observations screen BSLF Patient Record gt Main Patient Screen gt Observations screen OR Patient Record gt Main Patient screen gt Enhanced Primary Care gt Diabetes Cycle of Care screen OR Pathology HL7 results with LOINC codes 14
4. 14682 9 14683 7 CHOLESTEROL CHOLESTEROL SCHOLESTEROL SECHOLESTEROL TOTCHOLESTEROL 14647 2 HBA1C HBA1C GLYCOSYLATEDHB GLYCATEDHB HAEMOGLOBINA1C HBA HBA HPLC HBA1CFRACTION 17856 6 4548 4 HDL HDL HDLCHOLESTEROL CHOLESTEROLHDL HDL PROTECTIVE 14646 4 LDL LDL LDLCHOLESTEROL CHOLESTEROLLDL LDL ATHEROGENIC 22748 8 20 March 2014 PAGE 45 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 20 March 2014 MICROALBUMIN 14957 5 1754 1 1755 8 TRIGLYCERIDES TG TRIG TRIGLYCERIDES STRIGLYCERIDES SETRIGLYCERIDES TRIGLYCTOT 14927 8 30524 3 PAGE 46 of 46
5. Christine Chidgey CHD add Coronary Artery spasm Variant angina Prinzmetal angina and Percutaneous Transluminal angioplasty Mental Health add Bipolar ADHD Autism Dementia 06 09 2010 Christine Chidgey Measurements Physical Activity INR Medications Add Asthma Medications Review all Medication lists Update Vaccines list 06 10 2010 Christine Chidgey Rename Gardasil Immunisation to HPV Add Pap Smear codes collected Updates to results for Microalbumin and ACR Add Conditions STIs Add Pathology Results information 06 01 2011 Christine Chidgey Hypertension some old codes removed Hypertension Borderline White coat Portal Pregnancy and Preventative care MEE 31 03 2011 Christine Chidgey Fix error in Appendix 1 18 7 2011 Christine Chidgey Add additional terms to Hyperlipidaemia Add Gestational Diabetes Add medication Dabigatran BSLF Check Pathology results as well as manual entry ACR Add LOINCs to pathology 03 11 2011 Christine Chidgey Add ACR LOINC 14959 1 lab SNP Add FOBT pathology collection Appendix C 1 ii Screening exclusion conditions 20 March 2014 PAGE 3 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 13 02 2012 Christine Chidgey Add Diagnoses Musculoskeletal gt Inflammatory Arthritis Musculoskeletal gt Other Musculoskeletal Add Medications Pain Relief gt Narcotics Opioids Pain Relief gt Paracetamol Musculoskeletal gt Gout prepar
6. Data Mappings v1_16 APPENDIX C BEST PRACTICE DATA CATEGORY MAPPINGS APPENDIX C 1 CONDITIONS DATA CATEGORY MAPPINGS BP The data collection process collects conditions that are found on the Best Pratice Past History screen in both the active and inactive parts of the screen Chronic conditions are flagged as true for a patient if the condition is marked as either active or inactive From the list below only Asthma and Depression are regarded as being recoverable These conditions are flagged as true if they are marked as active only CAT Category Best Practice Mapping Diabetes Type II Diabetes Mellitus NIDDM Diabetes Mellitus Type 2 NIDDM Non insulin dependent Diabetes Mellitus Type 2 Diabetes Mellitus TypeI Diabetes mellitus IDDM Diabetes mellitus Type 1 IDDM Insulin dependent Diabetes mellitus Juvenile onset Diabetes mellitus Type 1 Diabetes mellitus Undefined diabetic Diabetes Diabetes controlled Diabetes Unstable Diabetes Mellitus Diabetic endarteritis Gestational Diabetes Diabetes Mellitus Gestational Gestational Diabetes Mellitus Gestational diabetes 20 March 2014 PAGE 7 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Respiratory Asthma Acute severe asthma Allergic asthma Allergy induced asthma Asthma Asthma review Asthma allergy induced Asthma exercise
7. Generic names Bisoprolol fumarate Carvedilol Product names Toprol XL Toprol XL Titration pack Beta Blockers Myocardial Infarction Generic names Atenolol Betaxolol hydrochloride Bisoprolol fumarate Carvedilol Esmolol hydrochloride Labetalol Hydrochloride Metoprolol Succinate Metoprolol Tartrate Oxprenolol Hydrochloride Pindolol Sotalol Sotalol Hydrochloride 20 March 2014 PAGE 24 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Calcium Antagonists Calcium Antagonists Generic names Amlodipine Amlodipine Besylate Amlodipine besylate atorvastatin Amlodipine Maleate Diltiazem Hydrochloride Diltiazem Hydrochloride Controlled Delivery Felodipine Lercanidipine Hydrochloride Nifedipine Ramipril Felodipine Trandolapril Verapamil Verapamil Hydrochloride Diuretics Diuretics Generic names Bendrofluazide Bumetanide Candesartan Cilexetil Candesartan Cilexetil Hydrochlorothiazide Diazoxide Enalapril Maleate Hydrochlorothiazide Eprosartan Mesylate Eprosartan Mesylate Hydrochlorothiazide Ethacrynic Acid Fosinopril Sodium Hydrochlorothiazide Frusemide Hydrochlorothiazide Hydrochlorothiazide Amiloride Hydrochlorothiazide Triamterene Hydrochlorothiazide Amiloride Hydrochlorothiazide Triamterene Indapamide Hemihydrate Irbesartan Hydrochlorothiazide Olmesartan medoxomil Hydrochlorothiaz
8. OR Today s Notes gt History and Examination gt Respiratory gt Calculator gt FEV1 and FVC INR Clinical gt INR Manager Physical Activity Clinical gt Physical Activity Prescription The prescription must be printed for it to be saved A selected current physical activity level of moderate or active meets the physical activity guidelines otherwise they do not meet the guidelines FOBT Pathology HL7 results with LOINC code 2335 8 27396 1 14563 1 14564 9 14565 6 12503 9 12504 7 27401 9 27925 7 27926 5 or with test names Faecal Occult Blood Faecal occult blood screening Faecal Occult Blood Test FOB FOBT Occult blood faeces Stool occult blood test OCCULT BLOOD faecal human haemoglobin Insure FOBT FOBT1 FOBT2 FOBT3 FOB1 FOB2 FOB3 FOBT Orders are extracted with any of the test names above eGFR Pathology HL7 results with LOINC code 33914 3 OR Calculation Refer Clinical Audit User Guide Part 2 Functionality Refer to pathology note at the start of this manual and Appendix C 6 20 March 2014 PAGE 40 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Pap Smear Best Practice Mapping Female Patient Record gt Main Patient Screen gt Cervical Smears tab Manual entry or Pathology HL7 results Recorded A smear test is listed Smear Date Date of most recent entry Best Practice Pap CCSR Smear HL7 M
9. Opiods Generic Names Codeine Tramadol Paracetamol Generics Paracetamol 20 March 2014 PAGE 33 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Musculoskeletal Gout preparations Class Musculoskeletal system Antigout preparations Osteoporosis medications Class Musculoskeletal system Drugs for treatment of bone disease Drugs affecting bone structure and mineralization Biphosphonates Generics Raloxifene Strontium ronelate Teriparatide DMARDS Conventional Generics aurorofin azothiaprine cyclosporin cyclophosphamide hydroxychloroquine leflunomide methotrexate mycophenolate penicillamine sulfasalazine DMARDS Biological Generics Cytokine modulators Abatacept Adalimumab Anakinra Etanacept Inflimaxib Rituximab Tocilizumab 20 March 2014 PAGE 34 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Appendix C 2 1 Immunisations Immunisations are collected if they have been entered in the Best Practice Immunisations screen The values collected for each type of immunisation are Influenza Pneumococcal HPV Pertussis Swine Flu FLUAD PNEUMOVAX 23 HPV ADACEL Panvax FLUVAX PNEUMOCOCCUS GARDASIL ADACEL POLIO H1N1 Influenza FLUARIX PREVENAR CERVARIX BOOSTRIX Panvax Junior FLUVAX JUNIOR PREVENAR 13 BOOST
10. colonic polyps Colonic polyp Colonic polyps Polyp colonic Polyps colonic Polyp rectal Polyps rectal Rectal polyp Rectal polyps Polyposis coli Rectal polyp removal Removal of rectal polyp Rectal polyp removal Rectal polypectomy Removal of rectal polyp Colonic polyp removal Colonic polypectomy Removal of colonic polyp 20 March 2014 PAGE 21 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 APPENDIX C 2 MEDICATIONS DATA CATEGORY MAPPINGS BP Medications Heart CAT Category Best Practice Mapping ACE or ARB ARB Generic names Candesartan Cilexetil Candesartan Cilexetil Hydrochlorothiazide Eprosartan Mesylate Eprosartan Mesylate Hydrochlorothiazide Irbesartan Irbesartan Hydrochlorothiazide Losartan Potassium Olmesartan medoxomil Olmesartan medoxomil Hydrochlorothiazide Telmisartan Telmisartan Hydrochlorothiazide Valsartan Amlodopine Valsartan Valsartan Hydrochlorothiazide ACE Inhibitors Generic names Captopril Enalapril Maleate Enalapril Maleate Hydrochlorothiazide Fosinopril Sodium Fosinopril Sodium Hydrochlorothiazide Lisinopril Perindopril Arginine Perindopril arginine Indapamide hemihydrate Perindopril Erbumine Perindopril erbumine Indapamide hemihydrate Quinapril Quinapril Hydrochlorothiazide Ramipril Ramipril Felodipine Trandolapril Trandolapril Verapamil
11. 771 0 14996 3 Cholesterol Lipids data HDL Patient Record gt Main Patient screen gt Enhanced Primary Care gt LDL Diabetes Cycle of Care screen Triglycerides OR Pathology HL7 results OR manually entered result Creatinine Patient Record gt Main Patient screen gt Enhanced Primary Care gt Diabetes Cycle of Care screen OR Pathology HL7 results OR manually entered result Urinary creatinine Pathology HL7 results with LOINC code 14683 7 Microalbumin Patient Record gt Main Patient screen gt Enhanced Primary Care gt Diabetes Cycle of Care screen OR Pathology HL7 results ACR Microalbumin Creatinine Ratio Pathology HL7 results with LOINC code 32294 1 30000 4 9318 7 or 14959 1 units mg mmol or g mol OR calculated from Microalbumin and Urinary Creatinine if results are on the same day OR manually entered result HbAlc Patient Record gt Main Patient screen gt Enhanced Primary Care gt Diabetes Cycle of Care screen OR Pathology HL7 results OR manually entered result OR Additional test name Blood haemoglobin A 1 c PAGE 39 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 BP Patient Record gt Main Patient screen either Opening the Observations screen or Opening the Enhanced Primary Care gt Diabetes Cycle of Care screen Respiratory Clinical gt Respiratory function Spirometry
12. Deficit Hyperactivity Disorder Hyperactivity r Autism Dementia Autism Autistic disorder Asperger s Syndrome Asperger s disorder Mental Health Degenerative Postnatal Depression Alzheimer s Disease Confusion Dementia Dementia with Lewy Bodies Dementia frontotemporal Dementia multi infarct Dementia Pick s Dementia semantic Dementia substance induced Dementia vascular Diffuse degenerative cerebral disease Disturbance of mentation Frontotemporal dementia Lewy body dementia Lobar atrophy of the brain Mental deterioration Multi infarct dementia Para schizaphrenia Pick s disease Semantic dementia Senile psychosis Senility Substance induced dementia Vascular Dementia Mental Health Other Active only conditions are collected Depression Postnatal Postnatal depression 20 March 2014 PAGE 14 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Musculoskeletal Inflammatory Arthritis ankylosing spondylitis Arteritis Giant cell Arthritis Juvenile Rheumatoid Arthritis Psoriatic Arthritis Rheumatoid Arthritis Seronegative Cranial arteritis CREST syndrome Disseminated Lupus Erythematosis Generalised Lupus Erythematosis Giant cell arteritis JRA Juvenile Rheumatoid Arthritis Juvenile Rheumatoid Arthritis Lupus Lupus Erythematosus Marie Strumpell disease MCTD Mixed connect
13. Enhanced Primary Care Diabetes Cycle of Care OR Pathology HL7 results Smoking Open Alcohol and Smoking History Tobacco PAGE 43 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 APPENDIX C 5 ASSIGNED PROVIDERS BP Assigned Provider Mapping in Best Practice Best Practice uses the Usual Doctor field in the patient demographics as the patients assigned provider Where a Usual Doctor is not selected patients will be assigned to a particular provider based on which provider they were most frequently seen by in recent consultations Providers that are inactive are excluded e Patients will be assigned to the active provider who saw them for the highest number of consultations in the previous 18 months e Where there is no consultation recorded in the previous 18 months the patient will be assigned to the active provider who saw them most recently up to 5 years ago e Where there is no consultation recorded in the previous 5 years no provider will be assigned 20 March 2014 PAGE 44 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 APPENDIX C 6 PATHOLOGY MAPPINGS BP CAT Pathology Result Best Practice HL7 Mapping Collected TEST NAME OR LOINC CODE ACR 32294 1 30000 4 9318 7 BSL 14749 6 BSLF 14771 0 CREATININE CREATININE SCREATININE SECREATININE
14. L DATA CATEGORY MAPPINGS BP Demographic Best Practice Mapping Gender Open gt Demographics screen gt Sex Ethnicity Open gt Demographics screen gt Drop down list for Aboriginal TSI DVA Open gt Demographics screen gt DVA No has a value Age Open gt Demographics screen gt DOB Last Visit Activity Past Visits screen gt Checks most recent date in the list Visits flagged as Type Non Visit are excluded Last Visit the most recent date recorded Active 3 or more visits recorded in the last 2 years Note The past visits screen in Best Practice can be used by practices to record non clinical contacts for example when a recall letter is sent These contacts must be flagged a type Non Visit to be excluded by CAT Postcode Open gt Demographics screen gt Postcode Allergy Best Practice Mapping Main Patient Screen gt Allergies Adverse Drug Reactions Box Allergy Recorded An Allergy Item is present No Known Allergies The Nil Known check box is checked Nothing Recorded No Allergy Items are present and the Nil Known check box is unchecked 20 March 2014 PAGE 37 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 20 March 2014 Smoking Daily Smoker Best Practice Mapping Main Patient screen gt Open gt Alcohol and Smoking History gt Tobacco Smoker Smoker is selected
15. PCS Clinical Audit Tool User Guide Version 3_10 1 APPENDICES C BEST PRACTICE DATA MAPPINGS v1 16 an FK PEN en Microson 7 COMPUTER ua M SYSTEMS sw Partner PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Company Contacts Sydney Head Office Document Contact Pen Computer Systems c EE Level 6 The Barrington gas dl 10 14 Smith St PARRAMATTA NSW 2150 Phone 61 3 9866 8477 Phone 61 2 9635 8955 AT 5 Email christine chidgeyOpencs com au Fax 612 9635 8966 Email enquiries pencs com au Web www pencs com au Melbourne Office Pen Computer Systems Level 5 434 St Kilda Rd MELBOURNE VIC 3004 Phone 61 3 9866 8477 Fax 61 3 9866 5699 20 March 2014 PAGE 2 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Document Control Version Date Modified By Description 20 05 2009 Christine Chidgey The CAT User Guide Appendices B C and D have been split out into separate documents These Appendices cover the Clinical Desktop System data mappings Add Waist and BSLF 282 20 07 2009 Christine Chidgey Add Assigned Provider Mapping 15 09 2009 Christine Chidgey Add Alcohol Update to assigned provider 29 06 2010 Christine Chidgey Pew conditions Peripheral Vascular Disease Carotid Stenosis Renal Artery Stenosis Chronic Renal Failure Revise condition CHD 17 08 2010
16. RIX IPV FLUVIRIN INFANRIX INFLUENZA INFANRIX HEXA INFLUVAC INFANRIX IPV INTANZA INFANRIX PENTA VAXIGRIP INFANRIX HEP B VAXIGRIP JUNIOR PEDIACEL PERTUSSIS PERTUSSIS MONAVALENT POLIACEL QUADRACEL TRIPACEL TRIPLE ANTIGEN 20 March 2014 PAGE 35 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 CHILDHOOD IMMUNISATIONS HepB DTPa Hib IPV Polio Pneumococcal conjugate Engerix B Paediatric Infanrix ActHib Adacel Polio Pneumococcus HBVax II Paediatric Infanrix Hexa HIB Boostrix IPV 7 valent Hepatitis B Infanrix IPV Hiberix Infanrix Hexa Prevenar Infanrix Hexa Infanrix Penta HibTITER Infanrix IPV Synflorix Infanrix Hep B Infanrix Hep B Infanrix Hexa Infanrix Penta Pneumococcus Infanrix Penta Tripacel PedvaxHIB IPOL 13 valent Comvax Triple Antigen ProHIBit Pediacel Prevenar 13 Twinrix Junior Pediacel Comvax Poliacel Poliacel Pediacel Polio Sabin Oral Quadracel Poliacel Poliomyelitis Quadracel Rotavirus MMR MenCCV HepA VZV Rotarix MMR I Meningitec Avaxim Varicella Zoster RotaTeq Priorix Menjugate Havrix 1440 Varilrix Rotavirus NeisVac C Havrix Junior Varivax Hepatitis A Twinrix 720 20 Twinrix Junior 360 10 VAQTA Adult VAQTA Paediatric Vivaxim 20 March 2014 PAGE 36 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 APPENDIX C 3 GENERA
17. _16 Renal Impairment Acute renal failure Chronic renal failure Haemodialysis Hepatorenal syndrome Kidney failure acute Kidney failure chronic Kidney failure Renal artery stenosis Renal dialysis Renal failure Renal failure acute Renal failure chronic Stenosis of renal artery Uraemia Dialysis Renal impairment Chronic Kidney Disease Chronic Kidney Disease Stage 1 5 Chronic Renal Failure Chronic renal failure Haemodialysis Kidney failure chronic Renal dialysis Renal failure chronic Dialysis Renal impairment Chronic Kidney Disease Chronic Kidney Disease Stage 1 5 Acute Renal Failure Acute renal failure Hepatorenal syndrome Renal failure acute Undefined Renal Failure Kidney failure Renal failure Uraemia 20 March 2014 PAGE 17 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Hyperlipidaemia Dyslipidaemia Familial hypercholesterolaemia Hyperlipidaemia Hyperlipidaemia type 2 Hyperlipoproteinaemia Type 2 High cholesterol Hypercholesterolaemia Drug Abuse Amphetamine abuse Active only conditions Amphetamine addiction Benzodiazepine abuse Benzodiazepine addiction Benzodiazepine dependence Benzodiazepine withdrawal Drug abuse Drug addict Drug addiction Drug dependence Drug seeking Drug withdrawal Heroin addiction Heroin dependence Intravenous drug use IV drug
18. ancy under the Obstetrics tab 20 March 2014 PAGE 19 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Appendix C 1 ii Screening exclusion Conditions Hysterectomy Abdominal hysterectomy Excluded from Pap Smear Hysterectomy Hysterectomy abdominal Hysterectomy subtotal Hysterectomy vaginal Partial hysterectomy Subtotal hysterectomy TAH Total Abdominal Hysterectomy Cancer of the Bowel Anal carcinoma Excluded from FOBT Cancer of the anus Carcinoma of the anus Squamous cell carcinoma of anus Adenocarcinoma of the colon Bowel cancer Cancer of the colon Carcinoma of the colon Colon carcinoma Colonic cancer Colonic carcinoma Cancer of the rectum Carcinoma of the rectum Rectal adenocarcinoma Rectal cancer Rectal carcinoma Genetic tendency to Hereditary nonpolyposis colorectal cancer Hereditary nonpolyposis colorectal carcinoma Lynch syndrome Carcinosarcoma of the colon Colon carcinosarcoma Signet ring cell carcinoma of bowel Signet ring cell carcinoma of rectum 20 March 2014 PAGE 20 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Polyps Familial adenomatous polyposis Excluded from FOBT Familial polyposis coli Gardner s syndrome Hereditary polyposis coli Multiple colonic polyps Polyposis coli Adenomatous colonic polyp Adenomatous
19. apping CERVICAL CONVENTIONAL SMEAR TEST NAME CERVICAL CYTOLOGY CERVICAL SMEAR Best Practice CERVICAL SMR automatically recognises CYTOLOGY GYNAECOLOGICAL HL7 items as pap smear CYTOLOGY GYNAECOLOGICAL PAP 0 results if they are this list GYNAE CYTOLOGY GYNAECOLOGICAL CYTOLOGY GYNEA CYTOLOGY NON SCREENING PAP NON SCREENING SMEAR PAP PAP BALLARAT PAP GEELONG PAP NS PAP SMEAR PAP SMEAR PAN 0 PAP SMEAR THIN PREP PAP SMEAR OLD PAP SMEARS PAP TEST PAP 0 PAP SMEAR PAPFU PAPR PAPR NS THIN PREP ONLY THINP VAG SM VAGINAL SMR VAULT CYTOLOGY VAULT SMEAR Practices should check the test names appearing in the results tab and advise PCS if there is a test name that should be added to this list Pap Smear Ineligible Best Practice Mapping 1 Cervical Smears screen tick box Not Required checked 2 Coded condition of Hysterectomy See Appendix B 1 ii Screening exclusions 20 March 2014 PAGE 41 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Disease Best Practice Mapping Condition Past History screen gt Checks the condition selected on history items where Conditions are selected from a coded list Refer to Appendix C 1 for a list of conditions mapping to each CAT condition Medications Best Practice Mapping Medication Current Rx screen gt Checks the Drugs listed as current medicat
20. arotid Stenosis Carotid Stenosis Carotid artery occlusion Renal Artery Stenosis Renal artery stenosis Stenosis of renal artery 20 March 2014 PAGE 12 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Mental Health Depression Anxiety Depression Depression Depression endogenous Depression Post Natal Depression reactive Endogenous depression Neurotic depression Organic depression Post Natal Depression Reactive depression Active only conditions are collected Anxiety Anxiety Anxiety disorder Anxiety neurosis Anxiety Depression Fear irrational GAD Generalised Anxiety Disorder Irrational fear Neurotic depression Phobia Phobic anxiety disorder Phobic disorder Social Anxiety Disorder Social phobia Schizophrenia Borderline schizophrenia Catatonic schizophrenia Chronic schizophrenia Paranoid schizophrenia Schizophrenia Schizophrenia borderline Schizophrenia catatonic Schizophrenia chronic Schizophrenia paranoid Bipolar Bipolar affective disorder Manic depressive illness Manic depressive psychosis Bipolar 1 disorder Bipolar 2 disorder 20 March 2014 PAGE 13 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Mental Health Developmental ADHD ADD ADHD Attention Deficit Disorder Attention
21. ations Musculoskeletal gt Osteoporosis medications Musculoskeletal gt DMARDs EN Jemen menses e Pi TA AA AAA e A A 4 9 12 Christine Chidgey Review and make additions to childhood vaccinations list Update definition of a visit 22 10 2012 Christine Chidgey Add additional pathology codes for Pap Smear HbAlc code and BSLF Add Review Date documentation for smoking and alcohol as 8 11 2012 Christine Chidgey Add Postnatal Depression to conditions 3 5 1 10 01 2013 Christine Chidgey Update details of Assigned Provide algorithm aan 20 02 2014 Christine Chidgey Update Antithrombotic medications 3 10 1 20 03 2014 Christine Chidgey Amendment to Antithrombotic medications documentation to clearly note the parent category contains a broader set of medications than the set of sub categories provided 20 March 2014 PAGE 4 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Contents DOCUMENPCONTA Ca dis 2 COMPANY CONTACTS RE iso coo 2 Sydney Head Office Mealbourne Office disi oben needed torte ed ER RR RR D n a RR Gu ER RR Fa P D ned E BR UR RR TRE XR UAR TR GER RR iau DOCUMENT CONTROL EE 3 sen gd gf 5 INTRODUCTION AAA tea sagesseceseassaxececeaadsd sacssed 6 CLINICAL AUDIT TOOL GAM EE 6 USER GUIDE e 6 PATHOLOGY RESULTS 15 55
22. de 20 March 2014 PAGE 28 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Metformin Generic names Metformin Hydrochloride Metformin Hydrochloride Glibenclamide Metformin Glibenclamide Rosiglitazone Maleate Metformin Hydrochloride Sitagliptin Metformin Glitazones Generic names Pioglitazone Hydrochloride Rosiglitazone Rosiglitazone Maleate Metformin Hydrochloride Mental Health Antipsychotics Generic names Amisulpride Aripiprazole Chlorpromazine Hydrochloride Clozapine Droperidol Flupenthixol Decanoate Fluphenazine Decanoate Fluphenazine Hydrochloride Haloperidol Haloperidol Decanoate Levomepromazine Olanzapine Paliperidone Pericyazine Pimozide Quetiapine Quetiapine fumarate Risperidone Thioridazine Thioridazine Hydrochloride Thiothixene Trifluoperazine Hydrochloride Ziprasidone Zuclopenthixol Acetate Zuclopenthixol Decanoate Zuclopenthixol Dihydrochloride 20 March 2014 PAGE 29 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Antipsychotics Typical Generic names Chlorpromazine Hydrochloride Droperidol Flupenthixol Decanoate Fluphenazine Decanoate Fluphenazine Hydrochloride Haloperidol Haloperidol Decanoate Levomepromazine Pericyazine Pimozide Thioridazine Thioridazine Hydrochloride Thiothixene T
23. eventers Product Names Accolate Alvesco Flixotide Intal Pulmicort Qvar Singulair Tilade Asthma Combination Product Names Seretide Symbicort 20 March 2014 PAGE 27 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Medications Other Antidiabetics H glycaemics Insulin Generic names Insulin Aspart Insulin aspart Insulin aspart rys Insulin Aspart Insulin Aspart Protamine Suspension Insulin detemir Insulin glargine Insulin glulisine Insulin Isophane N P H Bovine Insulin Isophane N P H Human Insulin lispro Insulin Lispro Insulin lispro Insulin lispro Protamine Suspension Insulin Lispro Insulin Lispro Protamine Suspension Insulin Neutral Bovine Insulin Neutral Human Insulin Neutral 20 Isophane 80 Human Insulin Neutral 30 Isophane 70 Human Insulin Neutral 30 Isophane 70 Human Insulin Neutral Bovine Insulin Neutral Isophane Human Insulin Neutral Isophane Human Insulin Zinc Suspension Human Neutral Insulin Human H glycaemics Oral Generic names Glibenclamide Gliclazide Glimepiride Glipizide Metformin Hydrochloride Metformin Hydrochloride Glibenclamide Metformin Hydrochloride Glibenclamide Metformin Glibenclamide Metformin Glibenclamide Pioglitazone Hydrochloride Rosiglitazone Rosiglitazone Maleate Metformin Hydrochloride Rosiglitazone Maleate Metformin Hydrochlori
24. ide Perindopril arginine Indapamide hemihydrate Quinapril Hydrochlorothiazide Telmisartan Hydrochlorothiazide 20 March 2014 PAGE 25 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Lipid M fying Statins Generic names Amlodipine besylate atorvastatin Atorvastatin Ezetimibe Simvastatin Fluvastatin Pravastatin Sodium Rosuvastatin Simvastatin Lipid M fying Other Generic names Cholestyramine Colestipol Hydrochloride Ezetimibe Ezetimibe Simvastatin Fenofibrate Gemfibrozil Nicotinic Acid Medications Respiratory Steroids Steroid Inhaled Generic Names Beclomethasone Dipropionate Budesonide Budesonide Eformoterol fumarate dihydrate Ciclesonide Fluticasone Propionate Fluticasone Propionate Salmeterol xinafoate Steroid Oral Generic Names Cortisone Acetate Prednisolone Prednisolone Acetate Prednisolone Hexanoate Prednisolone Sodium Phosphate Prednisone COPD COPD Generic Names Tiotropium 20 March 2014 PAGE 26 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Antiasthmatic Asthma Relievers Generic Names Salbutamol Sulfate Terbutaline Sulfate Product Names Atrovent Asthma Symptom Generic Names Controllers Eformoterol Fumarate Dihydrate Slameterol Xinafoate Asthma Pr
25. induced Asthma infective exacerbation Bronchial asthma Exercise induced asthma Exertional asthma Infective exacerbation of asthma Status asthmaticus Wheezy bronchitis Active only conditions are collected COPD Bronchitis chronic Chronic bronchitis Chronic Obstructive Airways Disease Chronic Obstructive Pulmonary Disease COAD COAD Infective exacerbation COPD Emphysema 20 March 2014 PAGE 8 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Cardiovascular CHD Acute coronary insufficiency Acute myocardial infarction AMI Angina Angina pectoris Angiogram coronary Angioplasty Angioplasty coronary Anterior myocardial infarct Anterolateral myocardial infarct Balloon coronary angioplasty CABG Coronary angiogram Coronary angiography Coronary Angiography No significant obstr Coronary angioplasty Coronary angioplasty with stent Coronary artery bypass graft Coronary artery disease Coronary artery endarterectomy Coronary Artery spasm Coronary artery stent Coronary endarterectomy Coronary heart disease Coronary insufficiency Coronary occlusion Heart attack IHD Inferior myocardial infarction Ischaemic heart disease MI Myocardial infarction Myocardial infarction anterior Myocardial infarction anterolateral Myocardial infarction inferior Myocardial infarction posterior Myocardial infarction s
26. ions where Drugs are selected from a coded list Refer to Appendix C 2 for a list of medications mapping to each CAT medication Medication Count Current Rx screen Counts All Drugs listed as current medications 20 March 2014 PAGE 42 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 APPENDIX C 4 DIABETES SIP DATA CATEGORY MAPPINGS BP 20 March 2014 Item Best Practice Mapping HbAlc Patient Record gt Main Patient screen gt Enhanced Primary Care gt Diabetes Cycle of Care screen OR Pathology HL7 results OR manually entered result OR Additional test name Blood haemoglobin A 1 c Eye Exam Enhanced Primary Care Diabetes Cycle of Care BMI Observations Waist Observations Or Enhanced Primary Care Diabetes Cycle of Care BSLF Observations screen OR Enhanced Primary Care Diabetes Cycle of Care screen OR Pathology HL7 results with LOINC codes 14771 0 14996 3 BP Observations Or Enhanced Primary Care Diabetes Cycle of Care Foot Exam Enhanced Primary Care Diabetes Cycle of Care Cholesterol Enhanced Primary Care Diabetes Cycle of Care OR Pathology HL7 results Triglycerides Enhanced Primary Care Diabetes Cycle of Care OR Pathology HL7 results HDL Enhanced Primary Care Diabetes Cycle of Care OR Pathology HL7 results Microalbumin
27. ist with its ongoing accreditation and provide opportunities to grow practice income The emphasis of the tool is to help practice staff to take specific action to improve patient coverage in chronic disease management and prevention User Guide The purpose of the User Guide is to provide instructions on how to install and use the functionality provided by the CAT The User Guide is split into 2 parts Part 1 Installation and Configuration including how to collect data sets Part 2 Functionality The Appendices for each Clinical Desktop System s Data Mappings are provided separately This full User Guide is available from http help pencs com au cat htm The Appendices contained in this document are for the Best Practice clinical system Pathology Results Pathology Results must be received in atomised HL7 format in order for the results to be picked up by the CAT extractor Atomised format means that the HL7 results contain the data in predefined coded segments The test name and LOINC Logical Observation Identifiers Names amp Codes code are the important bits of data the extraction tool looks for Best Practice maintains a list of test names and LOINC codes that automatically populate results into the patient s file Some additional codes are searched for by the extractor This list is provided in Appendix C 6 20 March 2014 PAGE 6 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice
28. ive tissue disease Polymyalgia rheumatica Polymyalgic Syndrome psoriatic arthritis RA Rheumatoid Arthritis Reiter s disease Reiter s syndrome Rheumatoid Arthritis Rheumatoid Arthritis Juvenile Scleroderma Seronegative arthritis Sicca syndrome Sjogren s disease Sjogren s syndrome SLE Systemic Lupus Erythematosus Stills Disease Systemic Lupus Erythematosis Temporal arteritis 20 March 2014 PAGE 15 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Other Musculoskeletal Gout Hyperuricaemia Gouty Arthritis Pseudogout Calcium pyrophosphate deposition disease Fibromyalgia Fibromyositis Myofascial pain syndrome Musculoskeletal Bone Disease Osteoporosis Osteopenia Osteoporosis Osteoporosis steroid induced Steroid induced osteoporosis Steroid osteopathy Osteoarthritis Ankle osteoarthritis Cervical spine osteoarthritis Hip osteoarthritis Hip osteoarthrosis Knee osteoarthritis Knee osteoarthrosis Lumbar spine osteoarthritis OA Osteoarthritis Osteoarthritis in neck Osteoarthritis cervical spine Osteoarthritis in fingers Osteoarthritis in hand Osteoarthritis in lumbar spine Osteoarthritis of ankle Osteoarthritis of hip Osteoarthritis of knee Osteoarthrosis 20 March 2014 PAGE 16 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1
29. monary Hypertension renovascular Idiopathic pulmonary hypertension Isolated systolic hypertension Labile Blood Pressure Labile BP Malignant hypertension Primary pulmonary hypertension Pulmonary hypertension Renal hypertension Renovascular hypertension Severe refractory hypertension Heart Failure Acute cardiac failure Acute heart failure Biventricular heart failure Cardiac failure Cardiac failure acute CCF Congestive cardiac failure Congestive heart failure Cor pulmonale Heart failure Heart failure acute Heart failure high output Heart failure left High output cardiac failure High output heart failure Hypertensive heart failure Left heart failure Left Ventricular Failure LHF LVF RHF Right heart failure Right ventricular failure RVF 20 March 2014 PAGE 11 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Stroke Cerebral haemorrhage Cerebral infarction Cerebrovascular Accident CVA Haemorrhage intracerebral Haemorrhagic CVA Haemorrhagic stroke Intracerebral bleed Intracerebral haemorrhage Intracranial haemorrhage Ischaemic stroke Lacunar Stroke Migrainous stroke Stroke Stroke haemorrhagic Stroke ischaemic Stroke lacunar Stroke migrainous Stroke thrombotic Thrombotic stroke Peripheral Vascular Disease Peripheral vascular disease Arteriosclerosis obliterans C
30. rifluoperazine Hydrochloride Zuclopenthixol Acetate Zuclopenthixol Decanoate Zuclopenthixol Dihydrochloride Antipsychotics Atypical Generic names Amisulpride Aripiprazole Clozapine Olanzapine Paliperidone Quetiapine Quetiapine fumarate Risperidone Ziprasidone 20 March 2014 PAGE 30 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Antidepressants Generic names Amitriptyline Hydrochloride Carbamazepine Citalopram Hydrobromide Clomipramine Hydrochloride Desvenlafaxine Dothiepin Hydrochloride Doxepin Hydrochloride Duloxetine Escitalopram Oxalate Fluoxetine Hydrochloride Fluvoxamine Maleate Imipramine Hydrochloride Mianserin Hydrochloride Mirtazapine Moclobemide Nortriptyline Hydrochloride Paroxetine Hydrochloride Phenelzine Sulfate Procarbazine Hydrochloride Reboxetine Mesilate Selegiline Hydrochloride Sibutramine Hydrochloride Tranylcypromine Sulfate Trimipramine Maleate Mood Stabiliser Lithium Generic names Lithium carbonate Anti anxiety Generic names Alprazolam Bromazepam Clobazam Clonazepam Diazepam Flunitrazepam Lorazepam Midazolam Nitrazepam Oxazepam Temazepam Triazolam 20 March 2014 PAGE 31 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Stimulants Generic names Atomoxetine hydrochloride Dexamphetamine S
31. ubendocardial Myocardial infarction superior Occlusion Coronary artery Percutaneous Transluminal angioplasty Posterior myocardial infarct Preinfarction syndrome Prinzmetal angina PTA Stent coronary artery Subendocardial infarct Subendocardial myocardial infarct 20 March 2014 PAGE 9 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Superior myocardial infarct Unstable angina Variant angina Acute Coronary Syndrome Acute coronary insufficiency Acute Coronary Syndrome Angina unstable Preinfarction syndrome Unstable angina Myocardial Infarction Acute myocardial infarction AMI Anterior myocardial infarct Anterolateral myocardial infarct Heart attack Inferior myocardial infarction MI Myocardial infarction Myocardial infarction anterior Myocardial infarction anterolateral Myocardial infarction inferior Myocardial infarction posterior Myocardial infarction subendocardial Myocardial infarction superior Posterior myocardial infarct Subendocardial infarct Subendocardial myocardial infarct Superior myocardial infarct 20 March 2014 PAGE 10 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Hypertension Essential hypertension High blood pressure Hypertension Hypertension Isolated systolic Hypertension malignant Hypertension pul
32. ulfate Methylphenidate Methylphenidate Hydrochloride Cortocosteroids Glucorticoids Generic names Beclomethasone Dipropionate Betamethasone acetate Betamethasone sodium phosphate Budesonide Budesonide Eformoterol fumarate dihydrate Ciclesonide Cortisone Acetate Dexamethasone Fluticasone Propionate Fluticasone Propionate Salmeterol xinafoate Hydrocortisone Hydrocortisone Acetate Hydrocortisone Sodium Succinate Hydrocortisone Cinchocaine Hydrochloride Methylprednisolone Acetate Methylprednisolone Sodium Succinate Prednisolone Prednisolone Hexanoate Cinchocaine Prednisolone Sodium Phosphate Prednisone Triamcinolone Acetonide 20 March 2014 PAGE 32 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Pain Relief Nsaids Generic names Diclofenac Potassium Diclofenac Sodium Diclofenac Sodium Misoprostol Ibuprofen Ibuprofen Codeine Ibuprofen Codeine Phosphate Ibuprofen Pseudoephedrine Hydrochloride Indomethacin Ketoprofen Ketorolac Trometamol Mefenamic Acid Naproxen Naproxen Sodium Piroxicam Pseudoephedrine hydrochloride Ibuprofen Sulindac Tiaprofenic Acid Celecoxib Etoricoxib Lumiracoxib Meloxicam Parecoxib Sodium Rofecoxib Cox2 Generic names Celecoxib Etoricoxib Lumiracoxib Meloxicam Parecoxib Sodium Rofecoxib Narcotics Opioids Class Nervous System gt Analgesics gt
33. use Long term opiate use Morphine addiction Morphine dependence Narcotic abuse Narcotic addiction Narcotic dependance Narcotic withdrawal Opiate abuse Opiate addiction Opiate dependence Opiate withdrawal Petrol sniffing Seeking drugs Solvent abuse Solvent dependence Substance abuse Withdrawal narcotic Withdrawal opiate are collected 20 March 2014 PAGE 18 of 46 PCS Clinical Audit Tool User Guide Ver 3 10 1 Appendices C Best Practice Data Mappings v1_16 Atrial Fibrillation AF Arrhythmia atrial fibrillation Atrial fibrillation Fibrillation atrial Rapid AF Rapid atrial fibrillation Chlamydia Active only conditions are collected Chlamydia Infection Chlamydia trachomatis infection Chlamydia urethritis Chlamydial PID PID chlamydial Urethritis chlamydial HIV Acquired immunodeficiency syndrome AIDS AIDS Related Complex ARC HIV HIV carrier HIV infection Human immunodeficiency virus carrier Human immunodeficiency virus infection Tuberculosis AIDS Gonorrhoea Active only conditions are collected Gonococcal infection Gonococcal proctitis Gonorrhoea Gonorrhoea rectal Proctitis gonococcal Rectal gonorrhoea Syphilis Active only conditions are collected Spirochete infection Syphilis Treponema pallidum infection Appendix C 1 i Pregnancy Pregnancy is true if the patient has a current pregn
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