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Core elements of a LOINC Record
LOINC Content - Documents
Each record contains:
- 6 part formal name, plus LOINC numerical number with check digit
- Additional meta data
- Class - DOC.CLINRPT, DOC.MISC
- Codes are never deleted
- Names are based on expected information content NOT document format
- Same LOINC for PDF, JPEG, DOC etc if information content is the same
What is NOT part of a LOINC Document Code
- Author
- Location of service
- Date of service
- Status (e.g. signed, unsigned)
- Security/privacy flags (e.g. protected)
- Updates or amendments to a document
- Other data is communicated in specific places of the electronic message
Document Names Model
Subject Matter Domain (LOINC Method)
- e.g. Cardiology, Pediatric Cardiology, Physical Therapy Role (LOINC Method)
- Author training/professional classification (not subspecialty) e.g. Physician, Nurse, Case Manager, Therapist, Patient Setting (LOINC System)
- Modest extension of Medicare/Medicade definition (not equivalent to location) e.g. Hospital, Outpatient, Emergency Department
Type of Service (LOINC Component)
- Service or activity provided to patient e.g. Consultation, History and Physical, Discharge Summary
Kind of Document (LOINC Component)
- General structure of the document e.g. Note, Letter, Consent
CORE ELEMENTS OF A DOCUMENT LOINC RECORD
Constructing a Document Code
- Document names are constructed from enumerated lists of values for each axis
- Lists can be found at: https://loinc.org/document-ontology/current-version/
- Detailed information about creating document codes can be found in the LOINC Users Manual in Section 7 (LOINC Document Ontology) https://loinc.org/download/loinc-users-guide/
Creating RFC’s for Documents
- InfoRMS (Infoway Request Management System) is Infoway’s Request for Change Tool
- Easy to use web-solution provides ability to request content additions or changes for pCLOCD
- May also be used to monitor progress of requests
- InfoRMS can be accessed at http://informs.infoway-inforoute.ca/
Mandatory fields for single RFC:
- Summary – Always use ‘Document Request: describe your document’
- Local Code – must provide a unique identifier for your request (suggested format XDC prefix to identify a document)
- LIS Test Name – provide the name of the document as it exists in your system today
- Time – always use Pt
- Specimen Type– the setting that the document is created in (Hospital, Outpatient, Emergency, {Setting})
- Qualitative or Quantitative – always choose Doc
- Order/Result or Both – always choose B
- Example Answers – always use ‘Document Code’
Optional fields for single RFC:
- LOINC Component – choose a Kind of Document and Type of Service (if required) from the enumerated list on line from Regenstrief
- LOINC Property – always choose Find
- Method - choose the Subject Matter Domain or Role of the person creating the document from the enumerated list on line
- Even though these are optional in InfoRMS, your RFC will not be processed if you don’t include the LOINC Component and Method
Contact information and Resources
- Canada Health Infoway https://www.infoway-inforoute.ca
- InfoCentral https://ic.infoway-inforoute.ca/
- InfoRMS http://informs.infoway-inforoute.ca/
- LOINC www.loinc.org