Coding clinical laboratory data for automatic storage and retrieval

Abstract

A series of clinical laboratory codes have been developed to accept and store urinalysis, blood chemistry, and hematology test results for automatic data processing. The codes, although constructed as part of a computerized hospital simulation, have been able to handle the results of every laboratory test that they have encountered. The unique feature of these codes is that they can accept conventionally recorded qualitative as well as quantitative test results. Consequently, clinical test results need not be arbitrarily stratified, standardized, or altered in any way to be coded. This paper describes how the codes were developed and presents a listing of the urinalysis codes. Five criteria used in developing the codes are outlined and the problem of multiple-synonymous terminology is discussed. A solution to the problem is described. Flexible, computer-produced, composite laboratory reports are also discussed, along with reproduction of such a report. The paper concludes that even though many problems remain unsolved, the next ten years could witness the emergence of a practical automated information system in the laboratory.