Recording COVID-19

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

Last updated: 6 May 2020

Recording exposure to, suspected and confirmed COVID-19

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 to record exposure to, suspected, probable and confirmed COVID-19. If you have non-SNOMED-enabled software, use the specified equivalent codes.

Further SNOMED CT concepts for coding COVID-19 symptoms, signs, complications, testing and surveillance are in development and available as pre-release content. We encourage early use of the new content to build knowledge of the virus. 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.

SNOMED CT concept and term Medtech code Profile code
840539006 | COVID-19 | @MT0.02 COVID19-1
50881000210106 | Probable COVID-19 @MT0.04   
840544004 | Suspected COVID-19 | @MT0.03 COVID19-2
840546002 | Exposure to SARS-CoV-2 | @MT0.01 COVID19-3*

*Exposure to COVID-19 is the term used.

The new 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 based on ICD-10-AM then use the following codes. 

ICD-10-AM ICD-10-AM code
COVID-19 (laboratory confirmed) U07.1
COVID-19 (clinically diagnosed or probable cases)  U07.2
Suspected COVID-19 (symptoms present and/or exposure to confirmed case)  Z03.8
Newborn (≤ 28 days) suspected COVID-19 (symptoms present and/or exposure to confirmed case) Z03.71
Suspected COVID-19 – testing performed - negative test result U06.0
Exposure to COVID-19 or to a confirmed case Z20.8
Mandated screening/testing for COVID-19 (no symptoms or history of exposure) Z11.5
Self-presenting for screening/testing for COVID-19 (no symptoms or history of exposure) Z71.1

Community-based assessment data collection

See the new 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 if you need more information.

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