Clinical Coding System

Standards and specifications

General requirements

Cyber security

The software must demonstrate ability to effectively achieve mitigation strategies in line with ‘Essential 8’.  

Privacy

Data collected in clinical coding system constitutes health information. Due to the sensitive nature of this information, it generally has a higher degree of privacy protection than other personal information, under relevant federal, state and territory legislations.

The software must demonstrate adherence to relevant federal, state or territory privacy legislation for example, the Privacy Act 1988 (Federal) or Health Records and Information Privacy Act 2002 (NSW).

The applicable federal legislation is the Privacy Act 1988.

Details of the relevant state and territory legislations are contained under the State and territory requirements section below.

Core requirements

Australian Core Data for Interoperability (AUCDI)

The system should support the use of AUCDI Release 2.

Note: Development is continuing to enhance AUCDI to include further elements to support clinical data and will continue to be published over time.

Standards for terminology, code sets and classifications  

The system should:

• support Systematised Nomenclature of Medicine-Clinical Terms AU (SNOMED CT-AU)
• support ICD-10-AM/ACHI/ACS classification system
• support the Australian Refined Diagnosis Related Groups (AR-DRG) classification
• support Standardised Pathology Informatics in Australia (SPIA)
• support Logical Observation Identifiers Names and Codes (LOINC®)
• support Australian Medicines Terminology (AMT)
• be capable of using METEOR for recording clinical information with data specifications
• be capable of using Nutrition Care Process Terminology (NCPT) (Dietary)
• support Rapid Response System (RRS) terminology
• support the National Clinical Terminology Service (NCTS).

State and territory requirements

The following state and territory requirements must be upheld based on location.