ISO_639-1 en false 2015-07-20 Ian McNicoll freshEHR Clinical Informatics, UK ian@freshehr.com Vebjørn Arntzen, Oslo University Hospital, Norway (openEHR Editor) Heidi Aursand, Oslo universitetssykehus, Norway Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) SB Bhattacharyya, Sudisa Consultancy Services, India Fatemeh Chalabianloo, Helse Bergen, Norway Anca Heyd, DIPS ASA, Norway Evelyn Hovenga, EJSH Consulting, Australia Nasjonal IKT, Norway Silje Kaada, Helse-Bergen, Avdeling for immunologi og transfusjonsmedisin, Norway Lars Morgan Karlsen, DIPS ASA, Norway Nils Kolstrup, Skansen Legekontor og Nasjonalt Senter for samhandling og telemedisin, Norway Liv Laugen, Oslo universitetssykehus, Norway Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Ole Martin Sand, DIPS ASA, Norway Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Paul Miller, SCIMP NHS Scotland, United Kingdom Andrej Orel, Marand d.o.o., Slovenia Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil Norwegian Review Summary, Nasjonal IKT HF, Norway Line Sæle, Nasjonal IKT HF, Norway Nyree Taylor, Ocean Informatics, Australia John Tore Valand, Helse Bergen, Norway (openEHR Editor) Wouter Zanen, Eurotranplant, Netherlands Lin Zhang, Taikang Insurance Group, China in_development 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/.0/. openEHR Foundation Pathology Test Result, Draft Archetype [Internet]. Australian Digital Health Agency, Australian Digital Health Agency Clinical Knowledge Manager [cited: 2017-06-27]. No longer available. Pathology (Data Specifications) Version 1.0 [Internet]. Sydney, Australia: National E-Health Transition Authority; 2007 May 29 [cited 2011 Jul 11]; No longer available. Laboratory Technical Framework, Volume 3: Content, Revision 3.0 [Internet]. USA: IHE International; 2011 May 19; [cited 2011 Jul 11]. Available from: https://www.ihe.net/Technical_Framework/upload/IHE_Lab_TF_Rev3-0_Vol3_FT_2011-05-19.pdf Hl7 FHIR Observation resource: HL7 [Internet]; [cited 2017 Jun 27]. Available from http://www.hl7.org/implement/standards/fhir/observation.html org.openehr openEHR Foundation org.openehr B7835C02E60A5281D1B1171AE2C762C1 69a962df-0118-4657-b3f7-02b9e47c0b09 0.0.1-alpha

ISO_639-1 de Dient zur Erfassung von Einzelresultaten für Labortest-Analyte, die in der klinischen Diagnostik verbreitet sind, wie z. B. biochemische, hämatologische, immunologische und transfusionsmedizinische Tests. Labor Pathologie Analyt Bestandteil Ergebnis Dient zur Erfassung von Einzelresultaten für Labortest-Analyte, die in der klinischen Diagnostik verbreitet sind, wie z. B. biochemische, hämatologische, immunologische und transfusionsmedizinische Tests. Diese können auch in anatomisch-pathologischen Berichten als 'zusätzliche Untersuchungen' vorkommen. Eine oder mehrere Instanzen dieses Archetyps können im 'test results' SLOT in OBSERVATION.laboratory_test_result verschachtelt werden. Unter Umständen kann dieser Archetyp in einem CLUSTER.laboratory_test_panel Archetypen verwendet werden - zusammen mit andere Analyten, die normalerweise als Teil eine Panels oder Profils getestet und/oder befundet werden. Dieser Archetyp kann im Rahmen einer komplexerem Labor/Pathologie-Befundung, z.B. in anatomisch-pathologischen Befunden verwendet werden, in denen oft quantitative Resultate, wie Durchfluss-Zytometrie-Analysen neben den üblichen makroskopischen und mikroskopischen Ergebnissen dokumentiert werden. Sollte nicht zur Befundung von anatomisch-pathologischen makroskopischen/mikroskopischen Ergebnissen verwendet werden, es sei denn für zusätzliche Tests, wie Durchfluss-Zytometrie-Analysen. Sollte nicht zur Befundung von mikrobiologischen Ergebnissen verwendet werden.

ISO_639-1 nb For å registrere ett enkelt laboratorieresultat innenfor områder som medisinsk biokjemi, hematologi, immunologi og transfusjonsmedisin. laboratorie analytt analyse svar resultat For å registrere ett enkelt laboratorieresultat innenfor områder som medisinsk biokjemi, hematologi, immunologi og transfusjonsmedisin. Arketypen kan også brukes til tilleggsundersøkelser innenfor patologi. En eller flere instanser av denne arketypen kan nøstes i SLOTet "Undersøkelsesresultat" i arketypen OBSERVATION.laboratory_test_result. I noen sammenhenger kan denne arketypen brukes i arketypen CLUSTER.laboratory_test_panel, sammen med andre analytter som vanligvis utføres sammen som del av en analysegruppe. Denne arketypen kan brukes innenfor mer komplekse laboratorie/patologirapporter der kvantitative svar som for eksempel flowcytometri rapporteres sammen med konvensjonelle makroskopiske og mikroskopiske undersøkelser. Skal ikke brukes til å registrere funn ved patologiundersøkelser, annet enn for tilleggsundersøkelser som flowcytometri. Skal ikke brukes til å registrere mikrobiologiresultater. © openEHR Foundation

ISO_639-1 pt-br Para gravar valores únicos e individuais de resultados laboratoriais de analitos comuns a testes patológicos clínicos como bioquímica, hematologia e imunologia. laboratório patologia analito componente resultado Para gravar valores únicos e individuais de resultados laboratoriais de analitos comuns a testes patológicos clínicos como bioquímica, hematologia e imunologia. Normalmente usados conjuntamente com o arquétipo parental OBSERVATION.laboratory_test_result e em algumas circunstâncias será carregado dentro de um arquétipo CLUSTER.laboratory_test_panel, junto com outros analitos que são normalmente testados e/ou reportados como parte de uma bateria, painel e perfil, embora não seja necessário e.e múltiplos analitos podem ser carregados diretamente dentro do OBSERVATION.laboratory_test. O atributo do nome do elemento "Resultado do analito" é normalmente substituído em uma especialização, template ou em tempo de execução para carregar o nome do analito específico, p.e., "hemoglobina", frequentemente codificado com uma terminologia de referência como LOINC, SNOMED CT ou NPU. Este arquétipo pode ser usado dentro do contexto de relatórios laboratoriais/de patologia mais complexos como em relatórios de histopatologia/anatomia onde resultados quantitativos como de estudos de citometria de fluxo e testes genéticos são frequentemente reportados junto com relatórios macroscópicos e microscópicos convencionais. Não deve ser usado para gravar achados detalhados de anatomia patológica macroscópica/microscópica, exceto para testes adicionais de estudos de citometria de fluxo ou testes genéticos.

ISO_639-1 en To record a single value laboratory analyte result, commonly found in clinical pathology testing such as medical biochemistry, haematology, immunology and transfusion medicine. laboratory pathology analyte constituent result Use to record a single value laboratory analyte result, commonly found in clinical pathology testing such as medical biochemistry, haematology, immunology and transfusion medicine. They may also be found in anatomical pathology reports as 'ancillary tests'. One or more instances of this archetype may be nested within the 'Test result' SLOT in the OBSERVATION.laboratory_test_result. In some circumstances this archetype may be carried within a CLUSTER.laboratory_test_panel archetype, together with other analytes which are normally tested and/or reported as part of a battery, panel or profile. This archetype may be used within the setting of more complex laboratory/pathology reporting such as anatomical pathology reports where quantitative results such as cytometric flow studies are often reported alongside conventional macroscopic and microscopic reporting. Not to be used to record anatomical pathology macroscopic/microscopic findings, other than for additional testing such as cytometric flow studies. Not to be used to record results for microbiological findings. © openEHR Foundation

ISO_639-1 de Michael Lieser Department of Infectious Diseases, Heidelberg University Hospital michael.lieser@med.uni-heidelberg.de ISO_639-1 nb Silje Ljosland Bakke Nasjonal IKT HF ISO_639-1 pt-br Adriana Kitajima, Débora Farage, Fernanda Maia, Laíse Figueiredo, Marivan Abrahão Core Consulting contato@coreconsulting.com.br Hospital Alemão Oswaldo Cruz (HAOC) a6e432f0-5b7a-4791-a655-2331efd00dce openEHR-EHR-CLUSTER.umg_laboranalyt_resultat.v0 1.4 at0000 CLUSTER true true false false 1 1 at0000 items true true false false 1 1 ELEMENT true true false false 0 1 at0027 value true true false false 0 1 DV_COUNT true true false false 1 1 ELEMENT true true false false 0 1 at0024 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true false true 0 at0001 CLUSTER true false true 0 at0014 archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint ELEMENT true true false false 0 1 at0004 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0025 value true true false false 0 1 DV_DATE_TIME true true false false 1 1 ELEMENT true true false false 0 1 at0005 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0015 at0016 at0017 at0018 at0020 at0019 at0021 at0023 at0022 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0006 value true true false false 0 1 DV_DATE_TIME true true false false 1 1 ELEMENT true true false false 0 1 at0026 value true true false false 0 1 DV_IDENTIFIER true true false false 1 1 DV_URI true true false false 1 1 ELEMENT true true false false 0 1 at0028 value true true false false 0 1 DV_DATE_TIME true true false false 1 1 value true true false false 1 1 DV_DATE_TIME true true false false 1 1 yyyy-mm-ddTHH:MM:SS ELEMENT true true false false 0 1 at0029 value true true false false 0 1 DV_IDENTIFIER true true false false 1 1 ELEMENT true true false false 0 1 at0030 value true true false false 0 1 DV_CODED_TEXT true true false false 1 1 defining_code true true false false 1 1 CODE_PHRASE true true false false 1 1 local at0032 at0033 at0034 at0035 at0036 at0037 at0038 at0039 at0040 at0041 ELEMENT true true false false 0 1 at0031 value true true false false 0 1 DV_DATE_TIME true true false false 1 1 value true true false false 1 1 DV_DATE_TIME true true false false 1 1 yyyy-mm-ddTHH:MM:SS ELEMENT true false true 0 at0003 value true true false false 0 1 DV_TEXT true true false false 1 1 false false true false true 1 Laboratory analyte result The result of a laboratory test for a single analyte value. Analyte result The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. OBX.2, OBX.5, OBX.6, OBX.7, OBX.8 Observation.value[x] Comment Additional narrative about the analyte result, not captured in other fields. NTE.3 Observation.note Reference range guidance Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range. For example, 'within normal limits for age and sex'. Result status The status of the analyte result value. 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'. OBX.11 Observation.status Result status time The date and time that the analyte result was issued for the recorded ‘Result status’. OBX.19 Observation.issued Analyte result detail Further detail regarding an individual result. Registered The existence of the test is registered in the Laboratory Information System, but there is nothing yet available. Partial This is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified. Preliminary Verified early results are available, but not all results are final. This is a sub-category of 'Partial'. Final The Test result is complete and verified by an authorised person. Corrected The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'. Amended The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed. Appended Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'. Entered in error The Test Result has been withdrawn following previous Final release. Cancelled The result is unavailable because the test was not started or not completed (also sometimes called 'aborted'). Analyte name The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. OBX.3 Observation.code Validation time The date and time that the analyte result was validated in the laboratory by a healthcare practitioner. In many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element. Specimen Identification of the specimen used for the analyte result. In some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens. Analyte result sequence The intended position of this analyte result within the overall sequence of analyte results. For example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit. *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *registered(en) *The existence of the report is registered, but there is nothing yet available.(en) *partial(en) *This is a partial (e.g. initial, interim or preliminary) report: data in the report may be incomplete or unverified.(en) *preliminary(en) *Verified early results are available, but not all results are final.(en) *final(en) *The report is complete and verified by an authorized person.(en) *amended(en) *Subsequent to being final, the report has been modified. This includes any change in the results, diagnosis, narrative text, or other content of a report that has been issued.(en) *corrected(en) *Subsequent to being final, the report has been modified to correct an error in the report or referenced results.(en) *appended(en) *Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged.(en) *cancelled(en) *The report is unavailable because the measurement was not started or not completed (also sometimes called "aborted").(en) *entered-in-error(en) *The report has been withdrawn following a previous final release. This electronic record should never have existed, though it is possible that real-world decisions were based on it. (If real-world activity has occurred, the status should be "cancelled" rather than "entered-in-error".).(en) *unknown(en) *The authoring/source system does not know which of the status values currently applies for this observation. Note: This concept is not to be used for "other" - one of the listed statuses is presumed to apply, but the authoring/source system does not know which.(en) Analyseresultat Resultatet av en individuell laboratorieanalyse. Analyseresultat Verdien av analyseresultatet. For eksempel "7,3 mmol/L" eller "Forhøyet". Datatypen "Udefinert datatype" må begrenses til en passende datatype i en spesialisering, et templat eller i applikasjonen. Datatypen Quantity har attributter fra referansemodellen som dekker flagg for normalt/unormalt, referanseområder og approksimeringer. Se https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for mer detaljer. OBX.2, OBX.5, OBX.6, OBX.7, OBX.8 Observation.value[x] Kommentar Ytterligere fritekst om analyseresultatet som ikke fanges opp av andre elementer. NTE.3 Observation.note Veileder for referanseområde Veileder for å finne ut om referanseverdien er relevant for dette resultatet. Kan inneholde tekst eller kodet tekstlig råd for om resultatet ligger innenfor normalområdet. For eksempel "innenfor normale grenseverdier i forhold til alder og kjønn". Resultatstatus Status for analyseresultatet. Verdiene er valgt spesifikt for å samsvare med verdiene i HL7 FHIR-ressursen "Diagnostic report", som historisk sett kommer fra praksis i HL7 v2. Andre lokale koder eller termer kan brukes ved å bruke datatypen "Fri eller kodet tekst. OBX.11 Observation.status Tidsangivelse for resultatstatus Datoen og tidspunktet da analyseresultatet ble utstedt for den aktuelle "Analyseresultatstatus". OBX.19 Observation.issued Detaljer om analyseresultat Ytterligere detaljer knyttet til et enkelt analyseresultat. Registrert Analysen er registrert i laboratoriesystemet, men resultatet er ikke tilgjengelig per nå. Ufullstendig Dette er et delvis (dvs initalt, foreløpig eller preliminært) svar: Data i resultatet kan være ukomplett eller ubekreftet. Foreløpig Verifiserte tidlige resultater er tilgjengelige, men ikke alle resultater er endelige. Dette er en underkategori av "Delvis". Endelig Resultatet er komplett og er bekreftet av ansvarlig person. Korrigert Resultatet har blitt modifisert etter å ha vært i status "Endelig", og er komplett og verifisert av ansvarlig laboratorielege. Dette er en underkategori av "Revidert". Revidert Resultatet har blitt modifisert etter å ha vært i status "Endelig", og er komplett og verifisert av ansvarlig laboratorielege, og resultatdata er endret. Tillegg Etter å ha vært satt som status "Endelig", har det blitt lagt nytt innhold til rapporten. Det eksisterende innholdet er uendret. Dette er en underkategori av "Revidert". Feilregistrert Analyseresultatet har blitt trukket tilbake etter å ha vært i status Endelig. Kansellert Resultatet er utilgjengelig fordi analysen ikke ble påbegynt eller ferdigstilt (også kalt "avbrutt"). Analysenavn Navnet på analyseresultatet. Verdien for dette elementet blir vanligvis lagt inn i en spesialisering av denne arketypen, i en templat, eller i applikasjonen. For eksempel "serum natrium" eller "hemoglobin". Det er sterkt anbefalt å kode dette elementet med en terminologi, for eksempel Norsk laboratoriekodeverk, NPU, LOINC, SNOMED CT eller lokale kodesett. OBX.3 Observation.code Tidsangivelse for validering Datoen og tidspunktet da analyseresultatet ble medisinsk validert i laboratoriet." I mange myndighetsområder omfatter "Resultatstatus" implisitt medisinsk validering, det vil si at et resultat med status "Endelig" vil antas å være medisinsk validert. I andre myndighetsområder kan dette registreres og rapporteres separat ved hjelp av dette dataelementet. Prøvemateriale Identifikator eller link til prøvematerialet som ble brukt i analysen. I noen situasjoner vil én Laboratorieresultat-arketype inneholde flere Prøvemateriale-arketyper og flere Analyseresultat-arketyper. I disse situasjonene må man bruke dette elementet for å kunne koble resultatene til de korrekte prøvematerialene. Resultatrekkefølge Plasseringen av dette analyseresultatet i den overordnede rekkefølgen av resultater. For eksempel "1", "2", "3". Dersom det er flere analyseresultater i en rapport gjør "Resultatrekkefølge" rekkefølgen i svarrapporten eksplisitt. *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *registered(en) *The existence of the report is registered, but there is nothing yet available.(en) *partial(en) *This is a partial (e.g. initial, interim or preliminary) report: data in the report may be incomplete or unverified.(en) *preliminary(en) *Verified early results are available, but not all results are final.(en) *final(en) *The report is complete and verified by an authorized person.(en) *amended(en) *Subsequent to being final, the report has been modified. This includes any change in the results, diagnosis, narrative text, or other content of a report that has been issued.(en) *corrected(en) *Subsequent to being final, the report has been modified to correct an error in the report or referenced results.(en) *appended(en) *Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged.(en) *cancelled(en) *The report is unavailable because the measurement was not started or not completed (also sometimes called "aborted").(en) *entered-in-error(en) *The report has been withdrawn following a previous final release. This electronic record should never have existed, though it is possible that real-world decisions were based on it. (If real-world activity has occurred, the status should be "cancelled" rather than "entered-in-error".).(en) *unknown(en) *The authoring/source system does not know which of the status values currently applies for this observation. Note: This concept is not to be used for "other" - one of the listed statuses is presumed to apply, but the authoring/source system does not know which.(en) *Laboratory analyte result(en) *The result of a laboratory test for a single analyte value.(en) *Analyte result(en) *The value of the analyte result.(en) *For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.(en) *OBX.2,OBX.5,OBX.6(en) *Observation.value[x](en) *Comment(en) *Additional narrative about the analyte result, not captured in other fields.(en) *NTE.3(en) *Observation.comments(en) *Reference range guidance(en) *Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.(en) *For example, 'within normal limits for age and sex'.(en) *Result status(en) *The status of the analyte result value.(en) *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'.(en) *OBX-11-observation result status(en) *status(en) *Result status time(en) *The date and time that the analyte result was issued for the recorded ‘Result status’.(en) *OBX-22 and/or OBX-19(en) *Observation.issued(en) Detalhes do resultado do analito Detalhes adicionais relativos a um resultado individual. Registrado A existência do teste é registrada no sistema de informação do laboratório, mas não há nada disponível ainda. Parcial Este é um resultado de teste parcial (p.e. inicial, intermediário ou preliminar): dados no resultado do teste podem estar incompletos ou não verificados. Preliminar Resultados iniciais verificados estão disponíveis, mas nem todos os resultados são definitivos. Esta é uma sub-categoria de "Parcial". Final O resultado final está completo e verificado por uma pessoa autorizada. *Corrected(en) *The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.(en) *Amended(en) *The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.(en) *Appended(en) *Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.(en) Entrada com erro O resultado do teste foi retirado após ser finalizado. Cancelado O resultado está indisponível porque o teste não foi iniciado ou não foi completado (algumas vezes chamado de "abortado"). *Analyte name(en) *The name of the analyte result.(en) *The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.(en) *OBX-3.1;3.2(en) *Observation.code(en) *Validation time(en) *The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.(en) *In many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.(en) *Specimen(en) *Identification of the specimen used for the analyte result.(en) *In some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.(en) *Analyte result sequence(en) * *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *registered(en) *The existence of the report is registered, but there is nothing yet available.(en) *partial(en) *This is a partial (e.g. initial, interim or preliminary) report: data in the report may be incomplete or unverified.(en) *preliminary(en) *Verified early results are available, but not all results are final.(en) *final(en) *The report is complete and verified by an authorized person.(en) *amended(en) *Subsequent to being final, the report has been modified. This includes any change in the results, diagnosis, narrative text, or other content of a report that has been issued.(en) *corrected(en) *Subsequent to being final, the report has been modified to correct an error in the report or referenced results.(en) *appended(en) *Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged.(en) *cancelled(en) *The report is unavailable because the measurement was not started or not completed (also sometimes called "aborted").(en) *entered-in-error(en) *The report has been withdrawn following a previous final release. This electronic record should never have existed, though it is possible that real-world decisions were based on it. (If real-world activity has occurred, the status should be "cancelled" rather than "entered-in-error".).(en) *unknown(en) *The authoring/source system does not know which of the status values currently applies for this observation. Note: This concept is not to be used for "other" - one of the listed statuses is presumed to apply, but the authoring/source system does not know which.(en) UMG_Laboranalyt-Resultat Ergebnis eines Labortests für einen bestimmten Analytwert. Beispiele: 'Natrium', 'Leukozytenzahl', 'T3'. Üblicherweise über eine externe Terminologie codiert. Analyt-Resultat (Mess-)Wert des Analyt-Resultats. z.B. '7.3 mmol/l', 'Erhöht'. Der 'Any'-Datentyp wird dann durch eine Spezialisierung, eine Vorlage oder zur Laufzeit auf einen passenden Datentypen eingeschränkt werden müssen, um das aktuelle Analyt-Ergebnis wiederzugeben. Der 'Quantity'-Datentyp hat Referenzmodell-Attribute, wie Kennungen für normal/abnormal, Referenzbereiche und Näherungen - für weitere Details s. https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class . OBX.2, OBX.5, OBX.6, OBX.7, OBX.8 Observation.value[x] Kommentar Kommentar zum Analyt-Resultat, soweit noch nicht in anderen Feldern erfasst. NTE.3 Observation.note Referenzbereichs-Hinweise Zusätzliche Hinweise zur Anwendbarkeit des Referenzbereichs für dieses Resultat oder (codierter) Text, ob das Resultat im Referenzbereich ist oder nicht. z.B.: 'im Referenzbereich, bezogen auf Alter und Geschlecht'. Ergebnis-Status Status des Analyseergebnisses. Die Werte wurden analog zum HL7 FHIR Diagnostic Report gewählt, die wiederum aus der HL7-Praxis stammen. Andere Codes/Ausdrücke können über den Text 'choice' verwendet werden. OBX.11 Observation.status Zeitpunkt Ergebnis-Status Datum und/oder Zeitpunkt an dem der Status für das Analyseergebnis gesetzt wurde. OBX.19 Observation.issued Analyseergebnis-Details Weitere Details zu einem einzelnen Ergebnis. Erfasst Der Test ist im Laborinformationssystem erfasst, aber noch kein Resultat verfügbar. Unvollständig Das Testresultat ist ein Anfangs- oder Interimswert, vorläufig oder nicht verifiziert/validiert. Vorläufig Erste, verifizierte Resultate sind vorhanden, der Test ist aber noch nicht abgeschlossen (Sub-Kategorie von 'Unvollständig'). Endbefund Das Testresultat ist vollständig und durch eine autorisierte Person verifiziert. Endbefund, korrigiert Der Endbefund wurde erneut modifiziert, ist vollständig und wurde durch den verantwortlichen Pathologen verifiziert. Dies ist eine Unterkategorie von "Endbefund, geändert". Endbefund, geändert Der Endbefund wurde erneut modifiziert, ist vollständig und wurde durch den verantwortlichen Pathologen verifiziert. Des Weiteren haben sich die Ergebnisdaten hierdurch verändert. Endbefund, ergänzt Nach Abschluss wurde der Bericht durch Hinzufügen neuer Inhalte abgeändert. Der vorhandenen Inhalte sind unverändert. Dies ist eine Unterkategorie von "Endbefund, geändert". Endbefund, widerrufen Das Testresultat wurde nach Endbefundung zurückgezogen. Storniert Das Testresultat ist nicht verfügbar, weil der Test nicht (vollständig) durchgeführt oder abgebrochen wurde. untersuchter Analyt Die Bezeichnung des Analyt-Resultats Der Wert dieses Elements wird normalerweise meist durch eine Spezialisierung, durch einer Vorlage oder zur Laufzeit geliefert, um den aktuellen Analyt wiederzugeben. Zum Beispiel: 'Natrium im Serum','Hämoglobin'. Die Codierung mit einer externen Terminologie, wie LOINC, NPU, SNOMED-CT oder lokalen Labor-Terminologien wird dringend empfohlen. OBX.3 Observation.code Zeitpunkt Validation Datum und Zeit, an dem das Analyseergebnis im Labor medizinisch validiert wurde. In vielen Gerichtsbarkeiten wird angenommen, dass der 'Ergebnisstatus' die medizinische Validation einschliesst, in anderen wird diese anhand dieses Datenelements separat erfasst und befundet Probe Kennung der Probe, die für das Analyseergebnis verwendet wurde. In manchen Situationen wird ein einzelner Laborergebnis-Archetyp mehrere Probe- und Laboranalyt-Resultat-Archetypen enthalten. In diesen Fällen wird dieses 'Probe'-Datenelement benötigt, um die Resultate mit den richtigen Proben zu verknüpfen. Analyseergebnis-Reihenfolge Die beabsichtigte Position dieses Analyseergebnisses in der Reihenfolge aller Analyseergebnisse z.B. '1', '2', '3'. Werden mehrere Analysenergebnisse berichtet, gibt die Analyseergebnis-Reihenfolge explizit die Reihenfolge der Analyseergebnisse an. Gültigkeitsdatum Zeitpunkt, zu dem die gemessene Eigenschaft im Probenmaterial (e.g. Analytkonzentration) mutmaßlich der Eigenschaft im Patienten entsprach. Wenn der Zeitpunkt der Probenentnahme angegeben ist, wird dieses Datum verwendet. Andernfalls wird behelfsmäßig der Probeneingang im Labor gewählt. Das "Gültigkeitsdatum" ist wichtig um verschiedene Analysen im Zeitverlauf sortieren zu können. ID der Laboranforderung Identifikator der Laboranforderung Status der Laboranforderung Status der Laboranforderung Anforderungsdatum Beschreibt das Datum, zu dem die Laboranforderung erstellt wurde. registered The existence of the report is registered, but there is nothing yet available. partial This is a partial (e.g. initial, interim or preliminary) report: data in the report may be incomplete or unverified. preliminary Verified early results are available, but not all results are final. final The report is complete and verified by an authorized person. amended Subsequent to being final, the report has been modified. This includes any change in the results, diagnosis, narrative text, or other content of a report that has been issued. corrected Subsequent to being final, the report has been modified to correct an error in the report or referenced results. appended Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged. cancelled The report is unavailable because the measurement was not started or not completed (also sometimes called "aborted"). entered-in-error The report has been withdrawn following a previous final release. This electronic record should never have existed, though it is possible that real-world decisions were based on it. (If real-world activity has occurred, the status should be "cancelled" rather than "entered-in-error".). unknown The authoring/source system does not know which of the status values currently applies for this observation. Note: This concept is not to be used for "other" - one of the listed statuses is presumed to apply, but the authoring/source system does not know which.