Demographic | Medical Director Mapping | |
Gender | Patient Details screen > Sex | |
Ethnicity | Patient Details screen > MD2: Tick boxes for Aboriginal / TSI MD3: Drop down list for Aboriginal and/or TSI, non ATSI, Not Recorded | |
DVA | Patient Details Screen > the Pension Status set to 'Full DVA' or 'Limited DVA' or the DVA No. field has a value | |
Age | Patient Details screen > DOB | |
Last Visit / Activity | Progress screen > Checks entries on previous visits list Last Visit = the most recent date recorded Active = 3 or more entries recorded in the last 2 years Note: The progress screen in Medical Director is used by some practices to record non clinical contacts, for example, when a recall letter is sent. These contacts cannot be distinguished from clinical contacts by CAT. | |
Postcode | Patient Details screen > Postcode | |
Allergy | Medical Director Mapping Patient Details > Allergies tab | |
Allergy Recorded | An Allergy Item is present | |
No Known Allergies | The 'No Known Allergies' check box is checked | |
Nothing Recorded | No Allergy Items are present and the 'No Known Allergies' check box is unchecked | |
Smoking | Medical Director Mapping Patient Details > Smoking tab > [Note that smoking data from the Diabetes record is not used. Adding data to the diabetes record does not update the smoking tab which is taken as the primary MD smoking data.] |
Daily Smoker | Smoker = Smoker is selected and frequency is daily |
Irregular Smoker | Smoker = Smoker is selected and frequency is not daily |
Ex Smoker | Smoker = Ex-Smoker is selected |
Never Smoked | Smoker = Never smoked is selected |
Nothing Recorded | Smoker has nothing selected |
Review Date | Date of Assessment [Note that this date only gets updated if something on the screen is changed] |
Alcohol | Medical Director Mapping Patient Details > Alcohol tab > Frequency = days a week patient usually drinks alcohol |
Drinker | Frequency = any except Never |
Non Drinker | Frequency = Never |
Nothing Recorded | Alcohol tab has nothing selected |
Review Date | Date of Assessment [Note that this date only gets updated if something on the screen is changed] |
Measurements /Pathology * | Medical Director Mapping |
BMI | Clinical > Diabetes Record > Add Values or Assessment OR Tools > Weight Calculator |
Waist | Tools > Weight Calculator |
FBG (BSLF) | Clinical > Diabetes Record > Add Values or Assessment OR Pathology HL7 results with LOINC codes 14771-0, 14996-3 |
Cholesterol | Clinical > Diabetes Record > Add Values or Assessment OR Pathology HL7 results |
HDL | Clinical > Diabetes Record > Add Values or Assessment OR Pathology HL7 results |
LDL | Clinical > Diabetes Record > Assessment OR Pathology HL7 results |
Triglycerides | Clinical > Diabetes Record > Add Values or Assessment OR Pathology HL7 results |
Creatinine | Clinical > Diabetes Record > Add Values or Assessment OR Pathology HL7 results |
Urinary creatinine | Pathology HL7 results with LOINC code 14683-7 |
Microalbumin | Clinical > Diabetes Record > Assessment (Microalbumin in units mg/L) OR Pathology HL7 results |
ACR (Microalbumin Creatinine Ratio) | Clinical > Diabetes Record > Assessment (Microalbumin ratio) OR 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 |
HbA1c | Clinical > Diabetes Record > Add Values or Assessment OR Pathology HL7 results OR Additional test name 'Blood haemoglobin A 1 c' |
BP | Clinical > Diabetes Record > Add Values or Assessment OR Tools > BP Monitor > Sitting |
Respiratory – Spirometry | Tools > Toolbox > Respiratory Calculator > FEV1 and FVC post values (entered manually or collected via a device) |
INR | Tools > Toolbox > INR Record > INR |
Physical Activity | Assessment > Physical Activity (or running man icon) A physical activity assessment is deemed as done if either an assessment or a prescription is recorded. Where an assessment has been done, if the score is > 5 the patient 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, 57905-2,56490-6,56491-4,29771-3 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,Faecal Occult Blood1,Faecal Occult Blood2, Faecal Occult Blood3, BOW, OCCULT BLOOD (OCB-0), OCCULT BLOOD (OCB-1), OCCULT BLOOD (OCB-2) FOBT Orders are extracted with any of the test names above. |
eGFR | Pathology HL7 results with LOINC code 33914-3 OR Renal Function Calculator OR Calculation (Refer Clinical Audit User Guide – Part 2 Functionality) |
Pap Smear | Medical Director Mapping |
| Female Patient Record > Smears tab |
Recorded | An entry is present on the tab |
Done Date | Date of most recent entry |
| Pathology HL7 Results |
Recorded | True if a result exists |
Done Date | Date of test result |
Test Name | CAT checks for the test names in the list below: PAP PAPR PAP NS PAPRNS PAP SMEAR PAP SMEARS PAP SMEAR(PAN-0) NON SCREENING SMEAR CERVICAL CYTOLOGY CERVICAL SMEAR CYTOLOGY GYNAECOLOGICAL (PAP-0) CERVICAL SMR GYNAECOLOGICAL CYTOLOGY CYTOLOGY GYNAECOLOGICAL PAP TEST PAP (GEELONG) PAP (BALLARAT) CCSR CERVICAL – CONVENTIONAL SMEAR PAP-0 (PAP SMEAR) PAP SMEAR +/- THIN PREP CYG CYTOLOGY-PAP SMEAR PAP SMEAR\T\THINPREP (PAP-0)CYTOLOGY GYNAECOLOGICAL PAP (P150) 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 | Medical Director Mapping |
| 1) Smear tab – ticked to exclude OR 2) Coded condition of Hysterectomy: |
Diseases | Medical Director Mapping |
Condition | Past History screen > Checks the condition selected on history items, where Conditions are selected from a coded list. Refer to the Appendices for a list of conditions mapping to each CAT condition. |
Medications | Medical Director Mapping |
Medication | Current Rx screen > Checks the Drugs listed, where Drugs are selected from a coded list Refer to the Appendices for a list of medications mapping to each CAT medication. |
Medication Count | Current Rx screen > Counts All Drugs listed as current medications |