Select a term for each investigation result as reported; do not together “lump” separate investigation results under an inclusive term unless reported as such. Example Reported LLT Selected Comment Abnormalities of liver Abnormal liver function function tests tests Select four individual Alkaline phosphatase terms for the Increased alkaline increased investigation results. A phosphatase, increased SGPT increased single term such as LLT SGPT, increased SGOT and SGOT increased Liver function tests elevated LDH LDH increased abnormal should not be selected 3.14.5 Investigation terms without qualifiers Terms in SOC Investigations without qualifiers may be used to record test names when entering diagnostic test data. Example Information/Reported LLT Selected for Test Name Comment (Verbatim) Cardiac output Cardiac output measured LLT Blood glucose increased should not be Increased blood sugar Blood glucose selected as it is both a test name and a result* * Enter a qualifier (e.g., or a numeric result (if available) into the “increased”) data field. “Result” 3.15 Medication/Administration Errors, Accidental Exposures and – Occupational Exposures 3.15.1 Medication/administration errors Medication errors are defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer.
Select a term for each investigation result as reported; do not “lump” together separate investigation results under an inclusive term unless reported as such. Example Reported LLT Selected Comment Abnormalities of liver function tests Abnormal liver function tests Increased alkaline phosphatase, increased SGPT, increased SGOT and elevated LDH Alkaline phosphatase increased SGPT increased SGOT increased LDH increased Select four individual terms for the investigation results. A single term such as LLT Liver function tests abnormal should not be selected 3.14.5 Investigation terms without qualifiers Terms in SOC Investigations without qualifiers may be used to record test names when entering diagnostic test data. Example Information/Reported (Verbatim) LLT Selected for Test Name Comment Cardiac output measured Cardiac output Increased blood sugar Blood glucose LLT Blood glucose increased should not be selected as it is both a test name and a result* * Enter a qualifier (e.g., “increased”) or a numeric result (if available) into the “Result” data field. 3.15 – Medication/Administration Errors, Accidental Exposures and Occupational Exposures 3.15.1 Medication/administration errors Medication errors are defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer.
9491-1610_termselptc_r4.6_sep2013.docx