PCS Clinical Audit Tool – User Guide

PCS Clinical Audit Tool – User Guide
PCS Clinical Audit Tool – User Guide
Version 3.3.1
APPENDICES C
BEST PRACTICE DATA MAPPINGS
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
Company Contacts
Sydney (Head Office)
Pen Computer Systems
Level 6, The Barrington
Document Contact
Contact:
Christine Chidgey
Phone:
+61 3 9866 8477
Email:
[email protected]
10-14 Smith St
PARRAMATTA NSW 2150
Phone: +61 2 9635 8955
Fax:
+61 2 9635 8966
Email:
[email protected]
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
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
Document Control
Version
2.5
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
2.5.2
20/07/2009
Christine Chidgey
Add Assigned Provider Mapping
2.6
15/09/2009
Christine Chidgey
Add Alcohol
Update to assigned provider
2.9
29/06/2010
Christine Chidgey
New conditions:
Peripheral Vascular Disease
Carotid Stenosis
Renal Artery Stenosis
Chronic Renal Failure
Revise condition CHD
2.9.3
17/08/2010
Christine Chidgey
CHD - add Coronary Artery spasm, Variant angina, Prinzmetal angina
and Percutaneous Transluminal angioplasty
Mental Health – add Bipolar, ADHD, Autism, Dementia
2.10
06/09/2010
Christine Chidgey
Measurements:
Physical Activity
INR
Medications
Add Asthma Medications
Review all Medication lists
Update Vaccines list
2.10.1
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
2.11
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
2.12
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
3.1
03/11/2011
Christine Chidgey
Add ACR LOINC 14959-1 (lab SNP)
Add FOBT pathology collection
Appendix C-1-ii Screening exclusion conditions
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
3.3
13/02/2012
Christine Chidgey
Version 3.3.1
Add Diagnoses:
•
Musculoskeletal > Inflammatory Arthritis
•
Musculoskeletal > Other Musculoskeletal
Add Medications
3.3.1
1 March 2012
27/02/2012
Christine Chidgey
•
Pain Relief > Narcotics/Opioids
•
Pain Relief > Paracetamol
•
Musculoskeletal > Gout preparations
•
Musculoskeletal > Osteoporosis medications
•
Musculoskeletal > DMARDs
Add Childhood Immunisations mappings
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
Contents
COMPANY CONTACTS ............................................................................................................................................................. 2
Sydney (Head Office) ..................................................................................................................................................... 2
Melbourne Office .......................................................................................................................................................... 2
DOCUMENT CONTACT ............................................................................................................................................................ 2
DOCUMENT CONTROL ............................................................................................................................................................ 3
CONTENTS .....................................................................................................................................................................5
INTRODUCTION .............................................................................................................................................................6
CLINICAL AUDIT TOOL (CAT) ................................................................................................................................................... 6
USER GUIDE ......................................................................................................................................................................... 6
PATHOLOGY RESULTS ............................................................................................................................................................. 6
APPENDIX C – BEST PRACTICE DATA CATEGORY MAPPINGS ..........................................................................................7
APPENDIX C-1 – CONDITIONS DATA CATEGORY MAPPINGS (BP) ...................................................................................... 7
APPENDIX C-1-I - PREGNANCY ............................................................................................................................................... 20
APPENDIX C-1-II SCREENING EXCLUSION CONDITIONS ................................................................................................................. 21
APPENDIX C-2 – MEDICATIONS DATA CATEGORY MAPPINGS (BP).................................................................................. 23
Medications - Heart .................................................................................................................................................... 23
Medications Other ...................................................................................................................................................... 27
APPENDIX C-2-1 IMMUNISATIONS .......................................................................................................................................... 35
APPENDIX C-3 – GENERAL DATA CATEGORY MAPPINGS (BP).......................................................................................... 37
APPENDIX C-4 – DIABETES SIP DATA CATEGORY MAPPINGS (BP).................................................................................... 43
APPENDIX C-5 – ASSIGNED PROVIDERS (BP) ................................................................................................................... 44
APPENDIX C-6 – PATHOLOGY MAPPINGS (BP) ................................................................................................................ 45
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PCS Clinical Audit Tool – User Guide – Appendices C: 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 quality 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 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 & 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.
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
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
Diabetes
Type II
Best Practice Mapping
Diabetes Mellitus, NIDDM
Diabetes Mellitus, Type 2
NIDDM
Non insulin dependent Diabetes Mellitus
Type 2 Diabetes Mellitus
Type I
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
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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
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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, 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
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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
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PCS Clinical Audit Tool – User Guide – Appendices C: 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
High output heart failure
Hypertensive heart failure
Left heart failure
Left Ventricular Failure
LHF
LVF
RHF
Right heart failure
Right ventricular failure
RVF
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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
Renal artery stenosis
Stenosis of renal artery
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PCS Clinical Audit Tool – User Guide – Appendices C: 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
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
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
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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 schizaphrenia
Pick’s disease
Semantic dementia
Senile psychosis
Senility
Substance induced dementia
Vascular Dementia
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
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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
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Other Musculoskeletal
Gout
Hyperuricaemia
Gouty Arthritis
Pseudogout
Calcium pyrophosphate deposition disease
Fibromyalgia
Fibromyositis
Myofascial pain syndrome
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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
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PCS Clinical Audit Tool – User Guide – Appendices C: 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
Dialysis
Renal impairment
Chronic Kidney Disease,
Chronic Kidney Disease, Stage 1-5
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
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Other
Hyperlipidaemia
Dyslipidaemia
Familial hypercholesterolaemia
Hyperlipidaemia
Hyperlipidaemia type 2
Hyperlipoproteinaemia, Type 2
High cholesterol
Hypercholesterolaemia
Drug Abuse
[Active only conditions
are collected]
1 March 2012
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
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
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Atrial Fibrillation
AF
Arrhythmia, atrial fibrillation
Atrial fibrillation
Fibrillation, atrial
Rapid AF
Rapid atrial fibrillation
Other - STIs
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 pregnancy under the Obstetrics tab.
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
Appendix C-1-ii Screening exclusion Conditions
Hysterectomy
Excluded from Pap Smear
Abdominal hysterectomy
Hysterectomy
Hysterectomy, abdominal
Hysterectomy, subtotal
Hysterectomy, vaginal
Partial hysterectomy
Subtotal hysterectomy
TAH
Total Abdominal Hysterectomy
Cancer of the Bowel
Excluded from FOBT
1 March 2012
Anal carcinoma
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
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Version 3.3.1
Polyps
Excluded from FOBT
1 March 2012
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
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
APPENDIX C-2 – MEDICATIONS DATA CATEGORY MAPPINGS (BP)
Medications - Heart
CAT Category
ARB
Best Practice Mapping
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
Aspirin
Generic names:
Aspirin
Aspirin, Glycine
Dipyridamole, Aspirin
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PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Warfarin
Version 3.3.1
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
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
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Calcium Antagonists
Version 3.3.1
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, Indapamide hemihydrate
Quinapril, Hydrochlorothiazide
Telmisartan, Hydrochlorothiazide
Lipid M/fying - Statins
Generic names:
Amlodipine besylate, atorvastatin
Atorvastatin
Ezetimibe, Simvastatin
Fluvastatin
Pravastatin Sodium
Rosuvastatin
Simvastatin
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Lipid M/fying - Other
Version 3.3.1
Generic names:
Cholestyramine
Colestipol Hydrochloride
Ezetimibe
Ezetimibe, Simvastatin
Fenofibrate
Gemfibrozil
Nicotinic Acid
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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 Hydrochloride
1 March 2012
PAGE 27 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Metformin
Version 3.3.1
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
1 March 2012
PAGE 28 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Antipsychotics – Typical
Version 3.3.1
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 C: Best Practice Data Mappings
Antidepressants
Version 3.3.1
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
1 March 2012
PAGE 30 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Stimulants
Version 3.3.1
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 C: Best Practice Data Mappings
Pain Relief
Nsaids
Version 3.3.1
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 > Analgesics > Opiods
Generic Names:
Codeine
Tramadol
Paracetamol
1 March 2012
Generics:
Paracetamol
PAGE 32 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Respiratory
Steroid – Inhaled
Version 3.3.1
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
Tilade
1 March 2012
PAGE 33 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Asthma - Combination
Version 3.3.1
Product Names:
Seretide
Symbicort
Musculoskeletal
Gout preparations
Osteoporosis medications
Class:
Musculoskeletal system > Antigout preparations
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
(Cytokine modulators)
Generics:
Abatacept
Adalimumab
Anakinra
Etanacept
Inflimaxib
Rituximab
Tocilizumab
1 March 2012
PAGE 34 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: 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
FLUVAX
FLUARIX
FLUVAX JUNIOR
FLUVIRIN
INFLUENZA
INFLUVAC
INTANZA
VAXIGRIP
VAXIGRIP JUNIOR
PNEUMOVAX 23
PREVENAR
PNEUMOCOCCUS
HPV
GARDASIL
CERVARIX
ADACEL
ADACEL POLIO
BOOSTRIX
BOOSTRIX IPV
INFANRIX
INFANRIX HEXA
INFANRIX IPV
INFANRIX PENTA
INFANRIX-HEP B
PEDIACEL
PERTUSSIS
PERTUSSIS
(MONAVALENT)
POLIACEL
QUADRACEL
TRIPACEL
TRIPLE ANTIGEN
Panvax
H1N1 Influenza
Panvax Junior
1 March 2012
PAGE 35 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
CHILDHOOD IMMUNISATIONS
HepB
DTPa
Hib
IPV (Polio)
7vPCV
Engerix B Paediatric
HBVax II Paediatric
Hepatitis B
Infanrix Hexa
Infanrix-Hep B
Infanrix
Infanrix Hexa
Infanrix IPV
Infanrix Penta
Infanrix-Hep B
Tripacel
Triple Antigen
ActHib
HIB
Hiberix
HibTITER
Infanrix Hexa
PedvaxHIB
ProHIBit
Pneumococcus (7
valent)
Prevenar
Synflorix
Rotavirus
MMR
MenCCV
Adacel Polio
Boostrix-IPV
Infanrix Hexa
Infanrix IPV
Infanrix Penta
IPOL
Pediacel
Poliacel
Polio Sabin (Oral)
Poliomyelitis
Quadracel
HepA
Rotarix
RotaTeq
Rotavirus
MMR II
Priorix
Meningitec
Menjugate
NeisVac-C
Avaxim
Havrix 1440
Havrix Junior
Hepatitis A
Twinrix (720/20)
Twinrix Junior
(360/10)
VAQTA Adult
VAQTA Paediatric
Vivaxim
Varicella-Zoster
Varilrix
Varivax
1 March 2012
VZV
PAGE 36 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
APPENDIX C-3 – GENERAL DATA CATEGORY MAPPINGS (BP)
1 March 2012
Demographic
Gender
Best Practice Mapping
Open > Demographics screen > Sex
Ethnicity
Open > Demographics screen >
Drop down list for Aboriginal / TSI
DVA
Open > Demographics screen > DVA
No. has a value
Age
Open > Demographics screen > DOB
Last Visit
Past Visits screen > Checks most recent
date in the list
Postcode
Open > Demographics screen >
Postcode
Allergy
Best Practice Mapping
Allergy Recorded
Main Patient Screen > Allergies /
Adverse Drug Reactions Box
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 C: Best Practice Data Mappings
Smoking
Version 3.3.1
Best Practice Mapping
Main Patient screen > Open > Alcohol
and Smoking History > 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 > Open > Alcohol
and Smoking History > Alcohol
Frequency = days a week patient usually
drinks alcohol
1 March 2012
Drinker
Frequency = any except Never
Non Drinker
Frequency = Never
Nothing Recorded
Alcohol tab has nothing selected
PAGE 38 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
Measurements
/Pathology *
BMI
Best Practice Mapping
Waist
Patient Record > Main Patient Screen > Observations screen
BSLF
Patient Record > Main Patient Screen > Observations screen
OR
Patient Record > Main Patient screen > Enhanced Primary Care >
Diabetes Cycle of Care screen.
OR
Pathology HL7 results
Cholesterol
HDL
LDL
Triglycerides
Lipids data :
Patient Record > Main Patient screen > Enhanced Primary Care >
Diabetes Cycle of Care screen.
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,
Patient Record > Main Patient Screen > Observations screen
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
1 March 2012
Patient Record > Main Patient screen > Enhanced Primary Care >
Diabetes Cycle of Care screen.
OR
Pathology HL7 results
OR manually entered result
PAGE 39 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
BP
Patient Record > Main Patient screen either
- opening the Observations screen, or
- opening the Enhanced Primary Care > Diabetes Cycle of Care
screen.
Respiratory Spirometry
Clinical > Respiratory function
OR
Today’s Notes >History and Examination > Respiratory > Calculator
> FEV1 and FVC
INR
Clinical > INR Manager
Physical Activity
Clinical > 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 C: Best Practice Data Mappings
Disease
Condition
Version 3.3.1
Best Practice Mapping
Past History screen > 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
Medication
Best Practice Mapping
Current Rx screen > 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
1 March 2012
Current Rx screen > Counts All Drugs listed as current
medications
PAGE 41 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: 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
Smear HL7 Mapping
TEST NAME
CCSR
CERVICAL CONVENTIONAL SMEAR
CERVICAL CYTOLOGY
CERVICAL SMEAR
CERVICAL SMR
CYTOLOGY GYNAECOLOGICAL
CYTOLOGY GYNAECOLOGICAL (PAP-0)
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.
1 March 2012
PAGE 42 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
Version 3.3.1
APPENDIX C-4 – DIABETES SIP DATA CATEGORY MAPPINGS (BP)
1 March 2012
Item
HbA1c
Best Practice Mapping
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 > 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 – Appendices C: Best Practice Data Mappings
Version 3.3.1
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.
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 C: Best Practice Data Mappings
Version 3.3.1
APPENDIX C-6 – PATHOLOGY MAPPINGS (BP)
1 March 2012
CAT Pathology Result
Collected
ACR
Best Practice HL7 Mapping
TEST NAME OR LOINC CODE
32294-1
30000-4
9318-7
BSLF
14771-0
CREATININE
CREATININE
SCREATININE
SECREATININE
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
MICROALBUMIN
14957-5
1754-1
1755-8
PAGE 45 of 46
PCS Clinical Audit Tool – User Guide – Appendices C: Best Practice Data Mappings
TRIGLYCERIDES
1 March 2012
Version 3.3.1
TG
TRIG
TRIGLYCERIDES
STRIGLYCERIDES
SETRIGLYCERIDES
TRIGLYCTOT
14927-8
30524-3
PAGE 46 of 46
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