PCS Clinical Audit Tool – User Guide
Contents
1. 1 March 2012 PAGE 28 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Antipsychotics Typical Generic names Chlorpromazine Hydrochloride Droperidol Flupenthixol Decanoate Fluphenazine Decanoate Fluphenazine Hydrochloride Haloperidol Haloperidol Decanoate Levomepromazine Pericyazine Pimozide Thioridazine Thioridazine Hydrochloride Thiothixene Trifluoperazine Hydrochloride Zuclopenthixol Acetate Zuclopenthixol Decanoate Zuclopenthixol Dihydrochloride Antipsychotics Atypical Generic names Amisulpride Aripiprazole Clozapine Olanzapine Paliperidone Quetiapine Quetiapine fumarate Risperidone Ziprasidone 1 March 2012 PAGE 29 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 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 Stab2. 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 pregnancy under the Obstetrics tab 1 March 2012 PAGE 20 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 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
3. 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 1 March 2012 PAGE 24 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 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 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 Hydrochlorothiazide Perindopril arginine Indapam
4. 35 APPENDIX C 3 GENERAL DATA CATEGORY MAPPINGS BP ssccsssccesssceesseecsssecsstecssseseesseesssseecsasecsensessaseeseesesseeeses 37 APPENDIX 4 DIABETES SIP DATA CATEGORY MAPPINGS BP i43 APPENDIX C 5 ASSIGNED PROVIDERS BP 3 e aaa 44 APPENDIX C 6 PATHOLOGY MAPPINGS BP E 45 1 March 2012 PAGE 5 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 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 guality and completeness of patient information The benefit to the practice is to assist 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
5. PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings 1 March 2012 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 Cholesterol Lipids data HDL Patient Record Main Patient screen Enhanced Primary Care LDL Diabetes Cycle of Care screen Triglycerides OR Pathology HL7 results OR manually entered result Creatinine Patient Record Main Patient screen Enhanced Primary Care 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 Main Patient screen Enhanced Primary Care 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 HbA1c Patient Record Main Patient screen Enhanced Primary Care Diabetes Cycle of Ca
6. High output heart failure Hypertensive heart failure Left heart failure Left Ventricular Failure LHF LVF RHF Right heart failure Right ventricular failure RVF 1 March 2012 PAGE 11 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 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 Cardiovascular Other Peripheral Vascular Disease Peripheral vascular disease Arteriosclerosis obliterans Carotid Stenosis Carotid Stenosis Carotid artery occlusion Renal Artery Stenosis artery stenosis Stenosis of renal artery 1 March 2012 PAGE 12 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Mental Health Depression Active only conditions are collected Anxiety Depression Depression Depression endogenous Depression Post Natal Depression reactive Endogenous depression Neurotic depression Organic depression Post Natal Depression Reactive depression Anxiet
7. INFLUENZA INFANRIX HEXA INFLUVAC INFANRIX IPV INTANZA INFANRIX PENTA VAXIGRIP INFANRIX HEP B VAXIGRIP JUNIOR PEDIACEL PERTUSSIS PERTUSSIS MONAVALENT POLIACEL QUADRACEL TRIPACEL TRIPLE ANTIGEN 1 March 2012 PAGE 35 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 CHILDHOOD IMMUNISATIONS HepB DTPa Hib IPV Polio 7vPCV Engerix B Paediatric Infanrix ActHib Adacel Polio Pneumococcus 7 HBVax II Paediatric Infanrix Hexa HIB Boostrix IPV 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 Tripacel PedvaxHIB IPOL Triple Antigen ProHIBit Pediacel Poliacel Polio Sabin Oral 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 1 March 2012 PAGE 36 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 APPENDIX C 3 GENERAL DATA CATEGORY MAPPINGS BP 1 March 2012 Demographic Best Practice Mapping Gender Open gt Demographics screen gt Sex Ethnicity O
8. 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 1 March 2012 PAGE 6 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 APPENDIX 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 Diabet
9. 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 1 March 2012 PAGE 21 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Polyps Excluded from FOBT Familial adenomatous polyposis Familial polyposis coli Gardner s syndrome Hereditary polyposis coli Multiple colonic polyps Polyposis coli Adenomatous colonic polyp Adenomatous 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 1 March 2012 PAGE 22 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 APPENDIX 2 MEDICATIONS DATA CATEGORY MAPPINGS BP Medications Heart CAT Category Best Practice Mapping ARB Generic names Candesartan Cilexetil Candesartan Cilexetil Hy
10. gt Paracetamol Musculoskeletal gt Gout preparations e Musculoskeletal gt Osteoporosis medications Musculoskeletal gt DMARDs Add Childhood Immunisations mappings PAGE 4 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Contents GOMPANY dee 2 Sydney Office EE 2 Melbourne OFFICE 2 EE 2 DOCUMENT CONTROL 3 CONTENTS aa AI EA Aaaa 5 INTRODUCTION E 6 AUDIT TOOL ME 6 USER GUIDE 6 PATHOLOGY toes bo e 6 APPENDIX C BEST PRACTICE DATA CATEGORY 7 APPENDIX C 1 CONDITIONS DATA CATEGORY MAPPINGS BP 7 Tdi deb Isa CEP 20 APPENDIX 1 1 SCREENING EXCLUSION CONDITIONS sessi eene enne 21 APPENDIX C 2 MEDICATIONS DATA CATEGORY MAPPINGS 23 Medications HeGFt vd o Fen 23 Medications OI 27 APPENDIX 2 1 YA YA TA SIC S yi Ta NKA
11. schizaphrenia Pick s disease Semantic dementia Senile psychosis Senility Substance induced dementia Vascular Dementia 1 March 2012 PAGE 14 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 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 connective 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 1 March 2012 PAGE 15 of 46 5 Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Other Musculoskeletal Gout Hyperuricaemia Gouty Arthritis Pseudogout Calcium pyrophosphate deposition disease Fibromyalgia Fibromyositis My
12. 55 8 1 March 2012 PAGE 45 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 TRIGLYCERIDES TG TRIG TRIGLYCERIDES STRIGLYCERIDES SETRIGLYCERIDES TRIGLYCTOT 14927 8 30524 3 1 March 2012 PAGE 46 of 46
13. PCS Clinical Audit Tool User Guide Version 3 3 1 APPENDICES C BEST PRACTICE DATA MAPPINGS CERTIFIED SYSTEMS 193 201 Partner PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Company Contacts Sydney Head Office Document Contact Pen Computer Systems Level 6 The Barrington Contact Christine Chidgey 10 14 Smith St PARRAMATTA NSW 2150 Phone 61 3 9866 8477 Phone 61 2 9635 8955 YAA Email christine chidgey Q pencs com au Fax 61 2 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 1 March 2012 PAGE 2 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Document Control Version Date Modified By Description 20 05 2009 Christine Chidgey The CAT User Guide Appendices B and D have been split out into separate documents These Appendices cover the Clinical Desktop System data mappings Add Waist and BSLF 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 New conditions Peripheral Vascular Disease Carotid Stenosis Renal Artery Stenosis Chronic Renal Failure Revise condition CHD 17 08 2010 Christine Chidgey CHD add Coronary A
14. YTOLOGY NON SCREENING PAP NON SCREENING SMEAR PAP PAP BALLARAT PAP GEELONG PAP NS PAP SMEAR PAP SMEAR 0 PAP SMEAR THIN PREP PAP SMEAR OLD PAP SMEARS PAP TEST 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 1 March 2012 PAGE 42 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 APPENDIX C 4 DIABETES SIP DATA CATEGORY MAPPINGS BP 1 March 2012 Item Best Practice Mapping HbA1c Enhanced Primary Care Diabetes Cycle of Care OR Pathology HL7 results Eye Exam Enhanced Primary Care Diabetes Cycle of Care BMI Observations Waist Observations Or Enhanced Primary Care Diabetes Cycle of Care BSLF Observations Or Enhanced Primary Care Diabetes Cycle of Care 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 Enhanced Primary Care Dia
15. 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 1 March 2012 PAGE 10 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Hypertension Essential hypertension High blood pressure Hypertension Hypertension Isolated systolic Hypertension malignant Hypertension pulmonary 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
16. betes Cycle of Care OR Pathology HL7 results Smoking Open Alcohol and Smoking History Tobacco PAGE 43 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 APPENDIX 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 In BP release 1 6 3 490 or later a change has been made to accommodate the case where a Usual Doctor is not selected In this case patients will be assigned to the provider with whom they have had the highest number of consultations in the previous 18 months 1 March 2012 PAGE 44 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 APPENDIX 6 PATHOLOGY MAPPINGS BP CAT Pathology Result Best Practice HL7 Mapping Collected TEST NAME OR LOINC CODE ACR 32294 1 30000 4 9318 7 BSLF 14771 0 CREATININE CREATININE SCREATININE SECREATININE 14682 9 14683 7 CHOLESTEROL CHOLESTEROL SCHOLESTEROL SECHOLESTEROL TOTCHOLESTEROL 14647 2 HBAIC 1 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 MICROALBUMIN 14957 5 1754 1 17
17. cute 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 subendocardial 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 1 March 2012 PAGE 9 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Superior myocardial infarct Unstable angina Variant angina Acute Coronary Syndrome Acute coronary insufficiency Acute Coronary Syndrome Angina unstable Preinfarction syndrome Unstable
18. drochlorothiazide 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 Eroumine Perindopril erbumine Indapamide hemihydrate Quinapril Quinapril Hydrochlorothiazide Ramipril Ramipril Felodipine Trandolapril Trandolapril Verapamil Aspirin Generic names Aspirin Aspirin Glycine Dipyridamole Aspirin 1 March 2012 PAGE 23 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Warfarin Generic names Warfarin Sodium Clopidogrel Generic names Clopidogrel Clopidogrel Aspirin Clopidogrel Hydrogen Sulfate Dabigatran Generic Names Dabigatran etexilate Beta Blockers Antihypertensive Generic names Atenolol Bisoprolol fumarate Carvedilol Labetalol Hydrochloride Metoprolol Succinate Metoprolol Tartrate Oxprenolol Hydrochloride Pindolol Propranolol Hydrochloride Beta Blockers Chronic heart failure
19. es 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 1 March 2012 PAGE 7 of 46 5 Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Respiratory Asthma Active only conditions are collected Acute severe asthma Allergic asthma Allergy induced asthma Asthma Asthma review Asthma allergy induced Asthma exercise induced Asthma infective exacerbation Bronchial asthma Exercise induced asthma Exertional asthma Infective exacerbation of asthma Status asthmaticus Wheezy bronchitis COPD Bronchitis chronic Chronic bronchitis Chronic Obstructive Airways Disease Chronic Obstructive Pulmonary Disease COAD COAD Infective exacerbation COPD Emphysema 1 March 2012 PAGE 8 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Cardiovascular CHD Acute coronary insufficiency A
20. ialysis Renal impairment Chronic Kidney Disease Chronic Kidney Disease Stage 1 5 1 March 2012 PAGE 18 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Other Hyperlipidaemia Dyslipidaemia Familial hypercholesterolaemia Hyperlipidaemia Hyperlipidaemia type 2 Hyperlipoproteinaemia Type 2 High cholesterol Hypercholesterolaemia Drug Abuse Active only conditions are collected Amphetamine abuse 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 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 1 March 2012 PAGE 19 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Atrial Fibrillation AF Arrhythmia atrial fibrillation Atrial fibrillation Fibrillation atrial Rapid AF Rapid atrial fibrillation Other STIs Chlamydia
21. ide hemihydrate Quinapril Hydrochlorothiazide Telmisartan Hydrochlorothiazide Lipid M fying Statins Generic names Amlodipine besylate atorvastatin Atorvastatin Ezetimibe Simvastatin Fluvastatin Pravastatin Sodium Rosuvastatin Simvastatin 1 March 2012 PAGE 25 of 46 5 Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Lipid M fying Other Generic names Cholestyramine Colestipol Hydrochloride Ezetimibe Ezetimibe Simvastatin Fenofibrate Gemfibrozil Nicotinic Acid 1 March 2012 PAGE 26 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 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 S
22. ilade 1 March 2012 PAGE 33 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Asthma Combination Product Names Seretide Symbicort Musculoskeletal Gout preparations Class Musculoskeletal system gt Antigout preparations Osteoporosis medications Class Musculoskeletal system gt Drugs for treatment of bone disease gt Drugs affecting bone structure and mineralization gt Biphosphonates Generics Raloxifene Strontium ronelate Teriparatide DMARDS gt Conventional Generics aurorofin azothiaprine cyclosporin cyclophosphamide hydroxychloroquine leflunomide methotrexate mycophenolate penicillamine sulfasalazine DMARDS gt Biological Generics Cytokine modulators Abatacept Adalimumab Anakinra Etanacept Inflimaxib Rituximab Tocilizumab 1 March 2012 PAGE 34 of 46 5 Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 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 PREVENAR GARDASIL ADACEL POLIO H1N1 Influenza FLUARIX PNEUMOCOCCUS CERVARIX BOOSTRIX Panvax Junior FLUVAX JUNIOR BOOSTRIX IPV FLUVIRIN INFANRIX
23. iliser Lithium Generic names Lithium carbonate Anti anxiety Generic names Alprazolam Bromazepam Clobazam Clonazepam Diazepam Flunitrazepam Lorazepam Midazolam Nitrazepam Oxazepam Temazepam Triazolam 1 March 2012 PAGE 30 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Stimulants Generic names Atomoxetine hydrochloride Dexamphetamine Sulfate 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 1 March 2012 PAGE 31 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Pain Relief Nsaids Generic names Diclofenac Potassium Diclofenac Sodium Diclofenac Sodium Misoprostol Ibuprofen Ibuprofen Codeine Ibuprofen Codeine Phosphate Ibuprofe
24. n 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 Opiods Generic Names Codeine Tramadol Paracetamol Generics Paracetamol 1 March 2012 PAGE 32 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Respiratory 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 Generic Names Tiotropium Asthma Relievers Generic Names Salbutamol Sulfate Terbutaline Sulfate Product Names Atrovent Asthma Symptom Controllers Generic Names Eformoterol Fumarate Dihydrate Slameterol Xinafoate Asthma Preventers Product Names Accolate Alvesco Flixotide Intal Pulmicort Qvar Singulair T
25. n 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 medications 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 gt Counts All Drugs listed as current medications 1 March 2012 PAGE 41 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Pap Smear Best Practice Mapping The Pap Smear data can be found in Best Practice by opening a Female Patient Record and from the Main Patient screen opening the Cervical Smears screen If there are smear tests they will be listed by date Patients with tick box Not Required checked are excluded Patients with a coded condition of Hysterectomy are also excluded See Appendix B 1 ii Screening exclusions Best Practice automatically recognises HL7 items as papsmear results if they are on the list below Best Practice Pap CCSR Smear HL7 Mapping CERVICAL CONVENTIONAL SMEAR TEST NAME CERVICAL CYTOLOGY CERVICAL SMEAR CERVICAL SMR CYTOLOGY GYNAECOLOGICAL CYTOLOGY GYNAECOLOGICAL PAP 0 GYNAE CYTOLOGY GYNAECOLOGICAL CYTOLOGY GYNEA C
26. ofascial pain syndrome 1 March 2012 PAGE 16 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 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 1 March 2012 PAGE 17 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Renal 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 Kidney failure Renal dialysis Renal failure Renal failure chronic Uraemia D
27. pen 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 Past Visits screen gt Checks most recent date in the list 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 PAGE 37 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Smoking Best Practice Mapping Main Patient screen gt Open gt Alcohol and Smoking History gt Tobacco Daily Smoker Smoker Smoker is selected 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 Alcohol Best Practice Mapping Main Patient screen gt Open gt Alcohol and Smoking History gt Alcohol Frequency days a week patient usually drinks alcohol Drinker Frequency any except Never Non Drinker Frequency Never Nothing Recorded Alcohol tab has nothing selected 1 March 2012 PAGE 38 of 46
28. re screen OR Pathology HL7 results OR manually entered result PAGE 39 of 46 Version 3 3 1 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 BP Patient Record gt Main Patient screen either opening the Observations screen opening the Enhanced Primary Care gt Diabetes Cycle of Care screen Respiratory Clinical gt Respiratory function Spirometry OR Today s Notes gt History and Examination gt Respiratory gt Calculator gt FEV1 and 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 FOBT Orders are extracted with any of the test names above Refer to pathology note at the start of this manual and Appendix C 6 1 March 2012 PAGE 40 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Disease Best Practice Mapping Conditio
29. rtery 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 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 1 March 2012 PAGE 3 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 1 March 2012 13 02 2012 27 02 2012 Christine Chidgey Christine Chidgey Add Diagnoses e Musculoskeletal gt Inflammatory Arthritis e Musculoskeletal gt Other Musculoskeletal Add Medications e Pain Relief gt Narcotics Opioids e Pain Relief
30. uspension 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 Hydrochloride 1 March 2012 PAGE 27 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 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
31. y 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 1 March 2012 PAGE 13 of 46 PCS Clinical Audit Tool User Guide Appendices Best Practice Data Mappings Version 3 3 1 Mental Health Developmental ADHD ADD ADHD Attention Deficit Disorder Attention Deficit Hyperactivity Disorder Hyperactivity r Autism Autism Autistic disorder Asperger s Syndrome Asperger s disorder Mental Health Degenerative Dementia 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
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