ARCHETYPE ID | openEHR-EHR-OBSERVATION.umg_laborergebnis.v0 |
Concept | Laboratory test result |
Description | The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual. |
Use | Use to record the result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual. This is typically done in a laboratory, but may be done in other environments such as at the point of care. This archetype is intended to cover the result of a single ordered investigation where the specimen(s) are collected as a single procedure, and may include multiple analyte results or other components. Examples of this could include 'Full blood count', which would yield a separate analyte result for the count of each type of blood cell, or 'kidney biopsy non-neoplastic', which would yield findings from microscopy, immunohistochemistry and electron microscopy. This archetype has been designed to be a framework that will usually be extended with CLUSTER archetypes to enable appropriate recording of specific laboratory test result patterns. This includes, but is not limited to, tests for biochemistry, haematology, immunology and transfusion services etc and specific patterns for the unique requirements for microbiology and anatomical pathology. If the ordered tests or investigations do not commonly belong together in a named group or panel, each test result would normally be represented using separate instances of this archetype. There is, however, considerable variation in actual reporting/messaging practice and this archetype/related archetypes are designed to handle such variation. This archetype supports multiple approaches to recording of specimen, reflecting current practice which varies enormously. A Laboratory test result has a high degree of alignment to an HL7 FHIR Diagnostic Report resource. It is anticipated that one or more instances of this archetype, or archetype family, will be sent back to a requesting clinician within a laboratory report document comprising COMPOSITION.report_result archetype, or similar, and other relevant ENTRY archetypes. The recording of confounding factors may be inconsistent, often depending on the analysing laboratory and on clinical information sent by the requester. In the State section of the archetype there is a simple 'Confounding factors' data element that is optional and can be repeated as one way to record a variety of simple factors that need to be made explicit as they may influence interpretation of the results. If the confounding factors are more complex, it may be appropriate to create a local/shared CLUSTER archetype that can be nested in the 'Confounding factors details' SLOT. Note 1: Known or required pre-conditions, such as 'fasting' or 'Day 1 of menstrual cycle', should be reported in the 'Sampling conditions' data element in the CLUSTER.specimen archetype, nested within this OBSERVATION archetype. Note 2: Known issues with specimen collection or handling, such as 'sample haemolysed' or 'prolonged use of tourniquet' should be reported within 'Specimen quality' in the CLUSTER.specimen archetype, nested within this OBSERVATION archetype. Where 'reflex tests' are performed by the laboratory, these may be handled as per US/FHIR guidance (see https://www.hl7.org/fhir/2015may/uslabreport-guide.html) or other local policy. For example, one of the following ... 1. Record the reflex test results additional 'Test findings' within the same 'openEHR-EHR-OBSERVATION.laboratory_test_result' 2. Record the reflex test results as 'Test findings' within a new 'openEHR-EHR-OBSERVATION.laboratory_test_result' but refer to the original lab test request via 'Test request details'. 3. Record the reflex test results as 'Test findings' within a new 'openEHR-EHR-OBSERVATION.laboratory_test_result' but reference a new lab test request as well as the original lab test request via 'Test request details'. |
Misuse | Not to be used to record an Autopsy or a Forensic report, although tests on some specimens that are taken in such situations may be represented using this archetype. For these, additional or specialised archetypes will be required to represent the data. This archetype is suitable for representation of general laboratory test results, but not intended to cover full synoptic reports. For these, additional specialising archetypes are required to represent the data. |
Purpose | To record the result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual. |
References | Based on Pathology Test Result, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-05-04]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.839 Pathology (Data Specifications) Version 1.0 [Internet]. Sydney, Australia: National E-Health Transition Authority; 2007 May 29 [cited 2011 Jul 11]; Available at http://www.nehta.gov.au/component/docman/doc_download/962-pathology-v10. Laboratory Technical Framework, Volume 3: Content, Revision 3.0 [Internet]. USA: IHE International; 2011 May 19; [cited 2011 Jul 11]. Available from: http://www.ihe.net/Technical_Framework/index.cfm#laboratory Hl7 FHIR Diagnostic Report resource: HL7 fhir; Available from http://www.hl7.org/implement/standards/fhir/diagnosticreport.html |
Copyright | © openEHR Foundation |
Authors | Author name: Ian McNicoll Organisation: freshEHR Clinical Informatics Email: ian@freshehr.com Date originally authored: 2015-07-20 |
Other Details Language | Author name: Ian McNicoll Organisation: freshEHR Clinical Informatics Email: ian@freshehr.com Date originally authored: 2015-07-20 |
OtherDetails Language Independent | {licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, references=Based on Pathology Test Result, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-05-04]. Available from: http://dcm.nehta.org.au/ckm/#showArchetype_1013.1.839 Pathology (Data Specifications) Version 1.0 [Internet]. Sydney, Australia: National E-Health Transition Authority; 2007 May 29 [cited 2011 Jul 11]; Available at http://www.nehta.gov.au/component/docman/doc_download/962-pathology-v10. Laboratory Technical Framework, Volume 3: Content, Revision 3.0 [Internet]. USA: IHE International; 2011 May 19; [cited 2011 Jul 11]. Available from: http://www.ihe.net/Technical_Framework/index.cfm#laboratory Hl7 FHIR Diagnostic Report resource: HL7 fhir; Available from http://www.hl7.org/implement/standards/fhir/diagnosticreport.html, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=22983C30881CF161FCC39E415B4356CE, build_uid=68e7e1be-3489-435c-952f-8352c583bb09, revision=0.0.1-alpha} |
Keywords | lab, pathology, biochemistry, haematology, microbiology, immunology, laboratory, anatomical, chemical, clinical, immunopathology, cytology, histopathology, test, biopsy, specimen, forensic, genetic, laboratory medicine, results, analysis |
Lifecycle | in_development |
UID | f62d480a-5904-4f6b-923a-468c1337da4c |
Language used | en |
Citeable Identifier | 1246.145.990 |
Revision Number | 0.0.1-alpha |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual., archetypeConceptComment=null, otherContributors=Andreas Abildgaard, OUS, Norway Yaser Abuhajjaj, United Arab Emirates Marit Alice Venheim, Helse Vest IKT, Norway Tomas Alme, DIPS ASA, Norway Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Koray Atalag, University of Auckland, New Zealand Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) Ryan Julius Banez, AC Health, Philippines Marcos Barreto, Universidade Federal da Bahia, Brazil Kristian Berg, Vestvågøy kommune - Fagutviklingsavdelingen, Norway SB Bhattacharyya, Sudisa Consultancy Services, India Sharmila Biswas, Dr Sharmila Biswas GP, Australia Johan Bjerner, Fürst, Norway Greg Burch, Tiny Medical Apps, United Kingdom Fatemeh Chalabianloo, Helse Bergen, Norway Doug Chesher, PaLMS, Australia Bjørn Christensen, Helse Bergen HF, Norway Stephen Chu, NEHTA, Australia (Editor) Matthew Cordell, NEHTA, Australia Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway Andre de Wolf, NeHTA, Australia Gail Easterbrook, Flinders Medical Centre, Australia Stig Erik Hegrestad, Helse Førde, Norway David Evans, Queensland Health, Australia David Fallas, Sysmex NZ Ltd, New Zealand Shahla Foozonkhah, Iran ministry of health and education, Iran Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom Heath Frankel, Ocean Informatics, Australia Frode Gilberg, PRIDOK AS, Norway Rosane Gotardo, Systema Ltda., Brazil Heather Grain, Llewelyn Grain Informatics, Australia Grahame Grieve, Health Intersections Pyty Ltd, Australia (Editor) Åshild Halvorsen, Helse Nord RHF, Norway martin hanlon, Careworks, United Kingdom Sam Heard, Ocean Informatics, Australia Anca Heyd, DIPS ASA, Norway Geir Hoff, Sykehuset Telemark HF, Norway Evelyn Hovenga, EJSH Consulting, Australia Silje Kaada, Helse-Bergen, Avdeling for immunologi og transfusjonsmedisin, Norway Lars Morgan Karlsen, DIPS ASA, Norway Mary Kelaher, NEHTA, Australia Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway Anne Kristin Strand, Sykehuspartner HF, Norway Tomi Laptoš, Marand, Slovenia Liv Laugen, Oslo universitetssykehus, Norway Michael Legg, Michael Legg & associates, Australia Sabine Leh, Haukeland University Hospital, Department of Pathology, Norway Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Neranga Liyanaarachchi, Ministry of Health, Postgraduate Institute of Medicine, Sri Lanka Zijian Li, China Jan-Arne Ludvigsen, DIPS AS, Norway Hallvard Lærum, Direktoratet for e-helse, Norway Manisha Mantri, C-DAC, India Siv Marie Lien, DIPS ASA, Norway Ole Martin Sand, DIPS ASA, Norway Mike Martyn, The Hobart Anaesthetic Group, Australia James McClay, University of Nebraska Medical Center, United States Andrew McIntyre, Medical-Objects, Australia David McKillop, NEHTA, Australia Hildegard McNicoll, freshEHR Clinical Informatics Ltd., United Kingdom Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Angela Merzweiler, University Hospital of Heidelberg, Germany Paul Miller, SCIMP NHS Scotland, United Kingdom Chris Mitchell, RACGP, Australia Stewart Morrison, NEHTA, Australia George Nikolaidis, Ergobyte Informatics S.A., Greece Bjørn Næss, DIPS AS, Norway Bjørn Odvar Eriksen, UNN, Norway Masafumi Okada, University of Tokyo, Japan Andrej Orel, Marand d.o.o., Slovenia Michael Osborne, Mater Health Services, Australia Vaclav Papez, University of West Bohemia, Czech Republic Anne Pauline Anderssen, Helse Nord RHF, Norway Ana Pereira, CINTESIS, CUF-Porto, Portugal Vladimir Pizzo, Hospital Sírio Libanês, Brazil Navin Ramachandran, NHS, United Kingdom Lars Retterstøl, OUS, Norway Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil David Rowed, VAMC Clinic, Australia (Editor) Marcus vinicius de Régis, NUTES, Brazil Mona Saleh (Translator) Diogo Schmidt, UNISINOS, Brazil Gro-Hilde Severinsen, Norwegian center for ehealthresearch, Norway Anoop Shah, University College London, United Kingdom Kyle Shore, Charm Health, Australia Hildegunn Siv Aase, Helse Bergen, Norway Niclas Skyttberg, Karolinska Institutet, Sweden Matt Stibbs, Digi-M Ltd., United Kingdom Iztok Stotl, UKCLJ, Slovenia Norwegian Review Summary, Nasjonal IKT HF, Norway Line Sæle, Nasjonal IKT HF, Norway Sveinung Sørbye, UNN HF, Norway Nyree Taylor, Ocean Informatics, Australia Tesfay Teame, Folkehelseinstittutet, Norway Rowan Thomas, St. Vincent's Hospital Melbourne, Australia Michael Thompson, Queensland Health, Australia Gordon Tomes, Australian Institute of Health and Welfare, Australia Richard Townley-O'Neill, NEHTA, Australia Katrin Troeltzsch, Nationales Centrum für Tumorerkrankungen (NCT); Universitätsklinikum Heidelberg, Germany Torleif Trydal, Fürst AS, Norway Gro-Hilde Ulriksen, Norwegian center for ehealthresearch, Norway John Tore Valand, Helse Bergen, Norway (openEHR Editor) Wouter Zanen, Eurotranplant, Netherlands Lin Zhang, Taikang Insurance Group, China, originalLanguage=en, translators=
openEHR-EHR-CLUSTER.specimen.v0 and specialisations or openEHR-EHR-CLUSTER.specimen.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0073], code=at0073, itemType=ELEMENT, level=4, text=Overall test status, description=The status of the laboratory test result as a whole., comment=The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'. This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
openEHR-EHR-CLUSTER.laboratory_ openEHR-EHR-CLUSTER.laboratory_ openEHR-EHR-CLUSTER.laboratory_ openEHR-EHR-CLUSTER.laboratory_ openEHR-EHR-CLUSTER.histopathology_ openEHR-EHR-CLUSTER.histopathology_ All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0118], code=at0118, itemType=SLOT, level=4, text=Multimedia representation, description=Digital image, video or diagram representing the test result., comment=Multiple formats are allowed but they should represent equivalent clinical content., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.multimedia.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0123], code=at0123, itemType=ELEMENT, level=4, text=*Neues Element(en), description=**(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=Full Date and Time, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0124], code=at0124, itemType=ELEMENT, level=4, text=*Neues Element(en), description=**(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=Full Date and Time, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0126], code=at0126, itemType=ELEMENT, level=4, text=*Neues Element(en), description=**(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0125], code=at0125, itemType=ELEMENT, level=4, text=*Neues Element(en), description=**(en), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0101], code=at0101, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the test result not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], credentials=[], target=[], items=[], content=[], description=[], contacts=[], state=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/state[at0112]/items[at0113], code=at0113, itemType=ELEMENT, level=4, text=Confounding factors, description=Issues or circumstances that impact on the accurate interpretation of the measurement or test result., comment='Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'. Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'. Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype. Coding with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/state[at0112]/items[at0114], code=at0114, itemType=SLOT, level=4, text=Structured confounding factors, description=Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result., comment=For example: Last Normal Menstrual Period (LNMP)., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: All not explicitly excluded archetypes, extendedValues=null]], events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=2, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=null, extendedValues=null]], provider=[], identities=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0017], code=at0017, itemType=SLOT, level=2, text=Receiving laboratory, description=Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects., comment=This slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects. The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0068], code=at0068, itemType=ELEMENT, level=2, text=Laboratory internal identifier, description=A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process., comment=This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0094]/items[at0035], code=at0035, itemType=SLOT, level=3, text=Distribution list, description=Details of additional clinicians or organisations who require a copy of the test result., comment=The 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.distribution.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0111], code=at0111, itemType=ELEMENT, level=2, text=Point-of-care test, description=This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation., comment=True if the test was performed directly at Point-of-Care (POCT)., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0121], code=at0121, itemType=ELEMENT, level=2, text=Test method, description=Description about the method used to perform the test., comment=Coding with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ANY, bindings=null, values=null, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0110], code=at0110, itemType=SLOT, level=2, text=Testing details, description=Structured details about the method of analysis, device or interpretation used., comment=For example: 'details of ELISA/nephelometry'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0117], code=at0117, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: All not explicitly excluded archetypes, extendedValues=null]]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=1..*, subCardinalityText= , dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], state=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/state[at0112], code=at0112, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items , dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0004], code=at0004, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items , dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0017], code=at0017, itemType=SLOT, level=2, text=Receiving laboratory, description=Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects., comment=This slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects. The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0068], code=at0068, itemType=ELEMENT, level=2, text=Laboratory internal identifier, description=A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process., comment=This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0094]/items[at0035], code=at0035, itemType=SLOT, level=3, text=Distribution list, description=Details of additional clinicians or organisations who require a copy of the test result., comment=The 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.distribution.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0111], code=at0111, itemType=ELEMENT, level=2, text=Point-of-care test, description=This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation., comment=True if the test was performed directly at Point-of-Care (POCT)., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0121], code=at0121, itemType=ELEMENT, level=2, text=Test method, description=Description about the method used to perform the test., comment=Coding with a terminology is desirable, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ANY, bindings=null, values=null, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0110], code=at0110, itemType=SLOT, level=2, text=Testing details, description=Structured details about the method of analysis, device or interpretation used., comment=For example: 'details of ELISA/nephelometry'., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0117], code=at0117, itemType=SLOT, level=2, text=Extension, description=Additional information required to capture local content or to align with other reference models/formalisms., comment=For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |