Recording COVID-19

Information for recording COVID-19 in a patient's health record.

Last updated: 12 October 2020

This information is for GPs, hospital clinicians and their software industry partners. It should be used to record details of COVID-19 in the affected patient's health record.

You should use the SNOMED CT codes in the table below for case classification, following the case definition and testing guidance for COVID-19. If you have non-SNOMED-enabled software, use the specified equivalent codes in the table.

Further SNOMED CT concepts related to COVID-19 are in development and available as pre-release content. We encourage early use of the new content to record symptoms and higher index of suspicion criteria. See the COVID-19 SNOMED CT Draft Guide published by SNOMED International for further information and the chance to review and contribute to revisions of the guide as it develops.

Concept SNOMED CT code Medtech code Profile code ICD-10-AM
Confirmed COVID-19 840539006 @MT0.02 COVID19-1 U07.1
Probable COVID-19 50881000210106 @MT0.04    U07.2
Under investigation COVID-19 840544004 @MT0.03 COVID19-2 Z03.8
Not a case 688232241000119100      

These SNOMED concepts and terms are included in the SNOMED CT International Edition March 2020 release except for new concept Probable COVID-19, which should be added separately.

Medtech32, Medtech Evolution, Intrahealth Profile, MyPractice and Best Practice Software systems should be configured to use their respective code sets.

If you are using hospital software that doesn't support SNOMED CT, then you should use the ICD-10-AM codes. 

Community-based assessment data collection

See the publication HISO 10082:2020 COVID-19 Community Based Assessment Data Standard and the related Community Based Assessment Data File Specification for the data collection requirements around patient assessment and sample taking for COVID-19.

This includes all assessments performed in fixed and mobile community-based assessment centres, hospital emergency departments, general practice, ambulance and other workplace and community settings.

Coding for COVID-19 laboratory tests

The March 2020 update to the NZ Pathology Observation Code Sets (NZPOCS) adds a set of COVID-19 test codes and descriptions for laboratories to code test results. See the LOINC website for more information about the new codes.

Contact [email protected] if you need more information.

Guidance for certifying deaths due to COVID-19

The Australian Bureau of Statistics (ABS) has developed guidelines for health practitioners to use when certifying causes of death for people who died of, or with COVID-19. These guidelines are based on World Health Organization recommendations so are applicable to all countries. The guidelines can be found at Guidance for Certifying Deaths due to COVID-19.

For information about certifying documents online see Completing death documents.

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