ISO_639-1 en false 2015-07-20 Ian McNicoll freshEHR Clinical Informatics ian@freshehr.com 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 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/. openEHR Foundation 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 org.openehr openEHR Foundation org.openehr 22983C30881CF161FCC39E415B4356CE 68e7e1be-3489-435c-952f-8352c583bb09 0.0.1-alpha

ISO_639-1 de Zur Dokumentation des Ergebnisses - einschließlich der Befunde und der Interpretation des Labors - einer Untersuchung, die an Proben durchgeführt wurde, die von einer Einzelperson stammen oder mit dieser Person zusammenhängen. Labor Pathologie Biochemie Hämatologie Mikrobiologie Immunologie Laboratorium anatomisch chemisch klinisch Immunpathologie Zytologie Histopathologie Untersuchung Biopsie Probe forensisch genetisch bedingt Labormedizin Ergebnisse Analyse Zur Dokumentation des Ergebnisses - einschließlich der Befunde und der Interpretation des Labors - einer Untersuchung, die an Proben durchgeführt wurde, die von einer Einzelperson stammen oder mit dieser Person zusammenhängen. Dies geschieht in der Regel in einem Labor, kann aber auch in anderen Bereichen, wie z.B. am Point of Care, durchgeführt werden. Dieser Archetyp soll das Ergebnis einer erforderlichen Einzeluntersuchung abdecken, bei der die Probe(n) über ein Einzelverfahren gesammelt werden, und kann mehrere Ergebnisse zu Analyten oder andere Komponenten enthalten. Beispiele hierfür könnte das „Vollblutbild“ sein, das ein separates Analyseergebnis für die Zählung jedes Blutzelltyps liefert, oder „Nierenbiopsie nicht neoplastisch“, das Ergebnisse aus der Mikroskopie, Immunhistochemie und Elektronenmikroskopie liefern würde. Dieser Archetyp wurde als Framework konzipiert, das in der Regel um CLUSTER-Archetypen erweitert wird, um eine angemessene Aufzeichnung spezifischer Labor-Testergebnismuster zu ermöglichen. Einschließlich aber nicht beschränkt auf: Tests für Biochemie, Hämatologie, Immunologie und Blutspendendienste etc. sowie spezifische Muster für die besonderen Anforderungen an Mikrobiologie und anatomische Pathologie. Wenn die in Auftrag gegebenen Tests oder Untersuchungen nicht gewöhnlich in einer benannten Gruppe oder einem benannten Panel zusammengehören, wird jedes Testergebnis in der Regel durch separate Instanzen dieses Archetyps dargestellt. Es gibt jedoch erhebliche Unterschiede in der tatsächlichen Berichts-/Messaging-Praxis, und dieser Archetyp/diese verwandten Archetypen sind so konzipiert, dass sie mit diesen Abweichungen umgehen können. Dieser Archetyp unterstützt mehrere Ansätze zur Erfassung von Proben und spiegelt die aktuelle, sehr unterschiedliche Praxis wieder. Ein Laborergebnis hat einen hohen Grad an Übereinstimmung mit einer HL7 FHIR Diagnoseberichtsquelle. Es wird erwartet, dass ein oder mehrere Exemplare dieses Archetyps oder dieser Archetypfamilie an einen anfragenden Arzt innerhalb eines Labordokuments zurückgeschickt werden, das COMPOSITION.report_result Archetyp, oder ähnliche und andere relevante ENTRY Archetypen. Die Erfassung von Störfaktoren kann inkonsistent sein, weil es oft vom Quelllabor und von den klinischen Informationen, die angefordert worden, abhängt. Im State-Abschnitt des Archetyps gibt es ein einfaches Datenelement "Confounding factors", das optional ist und als eine Möglichkeit wiederholt werden kann, eine Vielzahl von einfachen Faktoren zu erfassen, die explizit gemacht werden müssen, da sie die Interpretation der Ergebnisse beeinflussen können. Wenn die Störfaktoren komplexer sind, kann es sinnvoll sein, einen lokalen/gemeinsamen CLUSTER-Archetyp zu erstellen, der im SLOT "Confounding factors details" ergänzt werden kann. Hinweis 1: Bekannte oder erforderliche Voraussetzungen, wie z.B. "Fasten" oder "Tag 1 des Menstruationszyklus", sollten im Datenelement "Probenbedingungen" im Archetyp CLUSTER.Probe, verschachtelt innerhalb des OBSERVATION Archetypes, angegeben werden. Hinweis 2: Bekannte Probleme bei der Probenentnahme oder Behandlung, wie z.B. "Probe hämolysiert" oder "verlängerter Gebrauch von Tourniquet", sollten unter "Probenqualität" im Archetyp CLUSTER.Probe, verschachtelt innerhalb des OBSERVATION Archetypes, angegeben werden. Werden vom Labor "Reflextests" durchgeführt, können diese gemäß den US/FHIR-Richtlinien (siehe https://www.hl7.org/fhir/2015may/uslabreportguide.html) oder anderen lokalen Richtlinien durchgeführt werden. Zum Beispiel eine der folgenden Punkte.... 1. Protokollierung der Reflextestergebnisse zusätzliche "Testergebnisse" innerhalb derselben "openEHR-EHROBSERVATION.Laborergebnis". 2. Protokollierung der Reflextestergebnisse zusätzliche "Testergebnisse" innerhalb derselben "openEHR-EHROBSERVATION.Laborergebnis", verweisen Sie aber über "Testerforderungsdetails" auf den ursprünglichen Labortestantrag. 3. Protokollierung der Reflextestergebnisse zusätzliche "Testergebnisse" innerhalb derselben "openEHR-EHROBSERVATION.Laborergebnis" festhalten, aber über "Testerforderungsdetails" auf einen neuen Labortestantrag sowie den ursprünglichen Labortestantrag verweisen. Nicht zur Dokumentation eines Autopsieberichts oder eines forensischen Berichts verwenden. Einzelne Proben, die bei einer Autopsie oder einem forensischen Bericht entnommen werden, können jedoch mit diesem Archetyp dargestellt werden. Für diese sind zusätzliche spezialisierte Archetypen erforderlich, um die Daten zu dokumentieren. Dieser Archetyp eignet sich zur Darstellung allgemeiner Labortestergebnisse, jedoch nicht für vollständige synoptische Berichte. Für diese sind zusätzliche spezialisierte Archetypen erforderlich, um die Daten zu dokumentieren.

ISO_639-1 nb For å registrere resultat, funn og laboratoriets tolkning, av en laboratorieundersøkelse utført på prøvemateriale fra et individ eller relatert til individet. medisinsk biokjemi medisinsk mikrobiologi medisinsk genetikk klinisk farmakologi patologi immunologi og transfusjonsmedisin laboratorie lab anatomisk prøve rettsmedisinsk laboratoriemedisin generell kjemi materiale prøvemateriale lokalisasjon undersøkelse analyse metode (analysemetode) laboratoriespesialitet blodprøve serum plasma fullblod analytt kapillærprøver venøse prøver arterielle prøver prøvetaking immunopatologi cytologi histopatologi biopsi preparat immunhistokjemi immuncytokjemi molekylærgenetiske analyser histologi cytologi cervixcytologi obduksjon flowcytometri molekylær patologi elektronmikroskopi neuropatologi frysesnitt punksjonscytologi makrobeskjæring makroskopisk undersøkelse mikrobiologi bakteriologi virologi serologi molekylærdiagnostikk parasittologi mykologi protozologi immunologi medisinsk immunologi transfusjonsmedisin immunhematologi transplantasjonsimmunologi cellulær immunologi ex vivo cellelaboratorium hormonanalyser endokrinologi blodbank blodkomponenter hematologi kjemisk klinisk kjemi klinisk kjemi klinisk biokjemi metabolsk molekylærbiologi homeostase og trombose koagulasjon klinisk farmakologi farmakologi doping analyser klinisk fysiologi toksikologi rusmiddelanalyse misbruksdiagnostikk genetisk genetikk HTS-diagnostikk genpaneler farmakogenetikk cancer cytogenetikk preparat rettsmedisinsk Brukes for å registrere resultat, funn og laboratoriets tolkning, av en laboratorieundersøkelse utført på prøvemateriale fra et individ eller relatert til individet. Dette utføres typisk i et laboratorium, men kan også gjøres i andre miljøer, som for eksempel ved pasientnær analysering. Denne arketypen er ment å dekke resultatet av én rekvirert undersøkelse der prøvene er tatt i én prosedyre, og som kan ha flere analyseresultater eller andre komponenter. Eksempler på dette kan være "Differensialtelling av leukocytter", som gir et separat resultat for antallet av hver type hvite blodceller, eller "Nyrebiopsi ikke-neoplastisk", som gir resultater fra mikroskopi, immunohistokjemi og elektronmikroskopi. Denne arketypen er laget for å være et rammeverk som vanligvis vil utvides med CLUSTER-arketyper for å få en hensiktsmessig registrering og rapportering av spesifikke mønstre for laboratorieresultater. Dette kan omfatte analyser og undersøkelser innen kjemi (medisinsk biokjemi, hematologi, immunologi og transfusjonsmedisin, med mer), samt spesifikke mønstre for de unike behovene innenfor mikrobiologi og patologi. Hvis de rekvirerte analysene eller undersøkelsene ikke tilhører en navngitt gruppe, vil hvert resultat normalt representeres ved en separat instans av denne arketypen. Imidlertid er det stor variasjon på hvordan svarrapportering/meldingsformidling skjer, og denne arketypen er designet for å ivareta disse variasjonene. Denne arketypen støtter flere tilnærminger til å registrere informasjon om prøvematerialet, noe som reflekterer de store variasjonene innenfor dagens praksis. Laboratoriesvar-arketypen har høy grad av samsvar med HL7 FHIR-ressursen "Diagnostic Report". Det forventes at en eller flere instanser av denne arketypen, eller arketypefamilen vil bli sendt tilbake til rekvirenten i en laboratoriesvarrapport, for eksempel i arketypen COMPOSITION.report_result eller tilsvarende, og sammen med relevante ENTRY-arketyper. Registrering av konfunderende faktorer gjøres i praksis ikke på en konsistent måte, og avhenger av avsenderlaboratoriet og av den kliniske informasjonen som ble sendt med fra rekvirenten. I "State"-delen av arketypen er det et valgfritt og repeterbart element for "Konfunderende faktorer" som kan brukes til å registrere enkle faktorer, som fordi de kan påvirke tolkningen av resultatet må registreres eksplisitt. Dersom de konfunderende faktorene er mer komplekse kan det være hensiktsmessig å lage en CLUSTER-arketype som kan brukes i SLOTet "Strukturerte konfunderende faktorer". NB 1: Kjente eller nødvendige forutsetninger, som for eksempel "fastende" eller "dag 1 av menstruasjonssyklusen" bør registreres i elementet "Prøvetakingsforhold" i arketypen CLUSTER.specimen, og nøstes inn i denne OBSERVATION-arketypen. NB 2: Kjente problemer med prøvetaking eller prøvehåndtering, som for eksempel "hemolyse" eller "forlenget stase" bør registreres i elementet "Prøvekvalitet" i arketypen CLUSTER.specimen, og nøstes inn i denne OBSERVATION-arketypen. Der laboratoriet endrer analyser eller legger til analyser som oppfølging, kan disse håndteres etter veilledning fra HL7 FHIR (https://www.hl7.org/fhir/2015may/uslabreport-guide.html), eller etter lokale prosedyrer. For eksempel en av følgende: 1. Registrer de endrede analysene/tilleggsanalysene innenfor samme instans av denne arketypen. 2. Registrer de endrede analysene/tilleggsanalysene i en ny instans av denne arketypen, men referer til den opprinnelige rekvisisjonen ved hjelp av "Rekvisisjonsdetaljer". 3. Registrer de endrede analysene/tilleggsanalysene i en ny instans av denne arketypen, men referer til en ny rekvisisjon i tillegg til den opprinnelige rekvisisjonen, ved hjelp av "Rekvisisjonsdetaljer". Skal ikke brukes for å lagre en sammenstilling etter obduksjon eller rettsmedisinsk undersøkelse, selv om prøver av noen prøvematerialer som blir tatt i en obduksjon kan bli representert i denne arketypen. For å lage selve obduksjons- eller den rettsmedisinske rapporten må man bruke spesialiserte arketyper. Denne arketypen er passende for å representere generelle laboratoriesvar, men er ikke ment å dekke komplette sammendragsrapporter ("synoptic reports") innenfor patologi. For disse trengs det i tillegg spesialiserte arketyper.

ISO_639-1 ar-sy لتسجيل نتيجة اختبار المعمل, و التي قد يتم استخدامها لتسجيل اختبار ذي قيمة واحدة, و عادة ما يتم بعد ذلك المزيد من التخصيص أو الوضع في قالب لتمثيل اختبار متعدد القيم أو رتل من الاختبارات. و يمثل هذا النموذج كوالد (أب) للتخصيصات الأخرى لاختبارات معملية أكثر تحديدا مثل الميكروبيولوجيا و الهيستوباثولوجيا. المعمل - المختبر الباثولوجيا - المرضية الكيمياء الحيوية الدمويات الميكروبيولوجيا المناعيات - علم المناعة قد يستخدم لتسجيل نتيجة اختبار المعمل, و التي قد يتم استخدامها لتسجيل اختبار ذي قيمة واحدة, و عادة ما يتم بعد ذلك المزيد من التخصيص أو الوضع في قالب لتمثيل اختبار متعدد القيم أو رتل من الاختبارات. يتم بعد ذلك تقديم التقرير للطبيب السريري الذي قام بطلب الاختبار في سياق تقرير معملي متكامل. قد تكون التخصيصات أكثر مناسبة للتقارير المركبة مثل حالات الميكروبيولوجيا أو الهيستوباثولوجيا. © openEHR Foundation

ISO_639-1 en 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. lab pathology biochemistry haematology microbiology immunology laboratory anatomical chemical clinical immunopathology cytology histopathology test biopsy specimen forensic genetic laboratory medicine results analysis 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'. 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. © openEHR Foundation

ISO_639-1 zh-cn 用于记录针对组织和体液等标本所进行的病理学实验室检验项目的发现/所见和解释。这通常是由实验室来完成，但也可能会是在其他环境下完成的，如床旁。 实验室 医学实验室 临床实验室 中心实验室 检验科 化验室 化验科 病理学 检验医学 检验 医学检验 临床检验医学 临床检验 生物化学 生化 血液学 微生物学 免疫学 解剖学 化学 临床 免疫病理学 细胞学 组织病理学 试验 试验项目 检验项目 化验项目 报告项目 活组织检查 活检 标本 样本 样品 试样 法医学 遗传学 用于记录任何病理学实验室检验结果，包括作为某个组合型操作项目或手术的组成部分而进行的针对某种标本的某一检验项目所获得的结果。 可以采用模板或专用原始型来表达多种分析物的组套。 对于那些需要额外报告内容的，诸如组织病理学或微生物学之类较为复杂的检验项目，则应当采用专用的原始型来表达。 实验室检验报告与HL7 FHIR 诊断报告资源DiagnosticReport之间具有高度的一致性。 在完整的基于组合式文档的报告的背景下，通常会作为一个构成要素，回报给申请医生。 并非旨在用于报告非病理学检验结果，如影像学诊断、心电图或呼吸功能试验。 并非旨在用于表达完整的累积型报告。当前这一实验室检验结果原始型表达的仅仅是，累积型检验项目报告之中通常被视为纵列的结果集合之一。累积型报告是一种视图，是利用由多个观测指标OBSERVATION原始型所表示的结果构建而成。 并非旨在用于记录活组织检查报告，尽管可以采用此原始型来表示，针对活组织检查时所采集标本进行的检验项目。 此原始型适合于表达一般性的病理学检验结果，但并未打算涵盖完整的提要式报告。对于此类报告，则需要采用额外的特化性原始型来表达相应的数据。 此原始型在设计上已经支持临床病理学，但可能并不适合于其他种类的病理学用途。

ISO_639-1 de Sarah Ballout MHH-Hannover ballout.sarah@mh-hannover.de ISO_639-1 nb Vebjørn Arntzen/Silje Ljosland Bakke/Liv Laugen Oslo universitetssykehus HF/Nasjonal IKT HF/Oslo universitetssykehus, Norway ISO_639-1 ar-sy Mona Saleh ISO_639-1 zh-cn Lin Zhang N/A linforest@163.com N/A f62d480a-5904-4f6b-923a-468c1337da4c openEHR-EHR-OBSERVATION.umg_laborergebnis.v0 1.4 at0000 OBSERVATION true true false false 1 1 at0000 data true true false false 1 1 HISTORY true true false false 1 1 at0001 events true true false false 0 1 EVENT true false true 0 at0002 data true true false false 1 1 ITEM_TREE true true false false 1 1 at0003 items true true false false 0 1 ELEMENT true true false false 1 1 at0005 value true true false false 0 1 DV_TEXT true true false false 1 1 CLUSTER true false true 0 at0065 archetype_id/value matches {/openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v1 constraint ELEMENT true true false false 0 1 at0073 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 at0107 at0037 at0120 at0038 at0040 at0115 at0119 at0074 at0116 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0075 value true true false false 0 1 DV_DATE_TIME true true false false 1 1 ELEMENT true true false false 0 1 at0077 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0100 value true true false false 0 1 DV_TEXT true true false false 1 1 CLUSTER true false true 0 at0097 archetype_id/value matches {/openEHR-EHR-CLUSTER\.laboratory_test_analyte(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.laboratory_test_analyte(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.histopathology_findings(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.histopathology_findings(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.laboratory_test_analyte(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.laboratory_test_analyte(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.histopathology_findings(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.histopathology_findings(-[a-zA-Z0-9_]+)*\.v1 constraint ELEMENT true true false false 0 1 at0057 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true false true 0 at0098 value true true false false 0 1 DV_TEXT true true false false 1 1 CLUSTER true false true 0 at0122 archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint CLUSTER true false true 0 at0118 archetype_id/value matches {/openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1 constraint ELEMENT true true false false 0 1 at0123 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 at0124 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 at0126 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0125 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true false true 0 at0101 value true true false false 0 1 DV_TEXT true true false false 1 1 false false true false true 1 state true true false false 0 1 ITEM_TREE true true false false 1 1 at0112 items true true false false 0 1 ELEMENT true false true 0 at0113 value true true false false 0 1 DV_TEXT true true false false 1 1 CLUSTER true false true 0 at0114 archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint false false true false true 0 false false true false true 1 protocol true true false false 0 1 ITEM_TREE true true false false 1 1 at0004 items true true false false 0 1 CLUSTER true true false false 0 1 at0017 archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint ELEMENT true true false false 0 1 at0068 value true true false false 0 1 DV_IDENTIFIER true true false false 1 1 DV_TEXT true true false false 1 1 CLUSTER true false true 0 at0094 items true true false false 1 1 ELEMENT true false true 0 at0106 value true true false false 0 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0062 value true true false false 0 1 DV_IDENTIFIER true true false false 1 1 DV_TEXT true true false false 1 1 ELEMENT true true false false 0 1 at0063 value true true false false 0 1 DV_IDENTIFIER true true false false 1 1 DV_TEXT true true false false 1 1 CLUSTER true true false false 0 1 at0090 archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint CLUSTER true false true 0 at0035 archetype_id/value matches {/openEHR-EHR-CLUSTER\.distribution(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.distribution(-[a-zA-Z0-9_]+)*\.v1 constraint false false true false true 1 ELEMENT true true false false 0 1 at0111 value true true false false 0 1 DV_BOOLEAN true true false false 1 1 value true true false false 1 1 BOOLEAN true true false false 1 1 true true ELEMENT true true false false 0 1 at0121 CLUSTER true false true 0 at0110 archetype_id/value matches {/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/} Boolean 2007 false String archetype_id/value attribute C_STRING openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1 constraint CLUSTER true false true 0 at0117 archetype_id/value matches {/.*/} Boolean 2007 false String archetype_id/value attribute C_STRING .* constraint false false true false true 0 *Laboratory test result(en) *The result, including findings and interpretation, of a laboratory investigation performed on specimens from individuals or related materials(en) *Event Series(en) *@ internal @(en) إحدى الوقائع إحدى الوقائع *Tree(en) *@ internal @(en) *Tree(en) *@ internal @(en) *Test name(en) *Name of the laboratory investigation performed on the specimen(s). (en) *A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. (en) *Receiving laboratory(en) *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.(en) *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. (en) *Distribution list(en) *Details of additional clinicians or organisations who require a copy of the test result.(en) *The 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.(en) *Partial(en) *This is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.(en) *Final(en) *The Test result is complete and verified by an authorised person.(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) *Conclusion(en) *Narrative description of the key findings. (en) *For example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'. (en) *DiagnosticReport.conclusion(en) *Requester Order Identifier(en) *The local ID assigned to the test order by the order requester.(en) *Equivalent to the HL7 Placer Order Identifier.(en) *Receiver Order Identifier(en) *The local ID assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).(en) *Assigning an identifier to a request by the Laboratory lnformation System (LIS) enables tracking progress of the request and enables linking results to requests. It also provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler Order Identifier.(en) *Specimen detail(en) *Details about the physical substance that has been analysed, in the situation where all results in this test are derived from the same specimen.(en) *If the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. If there are multiple specimens, these may be represented per 'Result group'.(en) *Laboratory internal identifier(en) *A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process. (en) *This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test. (en) *Overall test status(en) *The status of the laboratory test result as a whole.(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'. 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. (en) *Cancelled(en) *The result is unavailable because the test was not started or not completed (also sometimes called 'aborted').(en) *Overall test status timestamp(en) *The date and/or time that ‘Overall test status’ was issued.(en) *Diagnostic service category(en) *The diagnostic service or discipline that is responsible for the laboratory test result. (en) *This is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible. (en) *Requester(en) *Details of the clinician or organisation requesting the laboratory test result.(en) *Test request details(en) *Details about the test request.(en) *In most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result. As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.(en) *Test result (en) *Results of the test performed on the specimen(s). (en) *This SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure. (en) *Test diagnosis(en) *Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result. (en) *For example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'. (en) *Clinical information provided(en) *Description of clinical information available at the time of interpretation of results.(en) *This data element may include a link to the original clinical information provided in the test request.(en) *DiagnosticReport.requestDetail.clinicalNotes(en) *Comment(en) *Additional narrative about the test result not captured in other fields.(en) *Original test requested name(en) *Name of the original laboratory test requested. (en) *This data element is to be used when the test requested differs from the test actually performed by the laboratory. (en) *Registered(en) *The existence of the test is registered in the Laboratory Information System, but there is nothing yet available.(en) *Testing details (en) *Structured details about the method of analysis, device or interpretation used.(en) *For example: 'details of ELISA/nephelometry'.(en) *Point-of-care test(en) *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.(en) *True if the test was performed directly at Point-of-Care (POCT).(en) *Tree(en) *@ internal @(en) *Confounding factors(en) *Issues or circumstances that impact on the accurate interpretation of the measurement or test result.(en) *'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. (en) *Structured confounding factors (en) *Details of patient state that may alter interpretation of the laboratory test.(en) *For example: Last Normal Menstrual Period (LNMP). (en) *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) *Entered in error(en) *The Test Result has been withdrawn following previous Final release.(en) *Extension(en) *Slot to allow extension to support localisation or alignment with other standards/ reference models.(en) *Multimedia representation(en) *Digital image, video or diagram representing the test result.(en) *Multiple formats are allowed but they should represent equivalent clinical content.(en) *DiagnosticReport.presentedForm(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) *Preliminary(en) *Verified early results are available, but not all results are final. This is a sub-category of 'Partial'.(en) *Test method (en) * *Coding with a terminology is desirable, where possible. (en) *Structured test diagnosis (en) *A structured or complex diagnosis for the laboratory test. (en) *For example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function. (en) *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) Laboratory test result The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual. Event Series @ internal @ Any event Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. Tree @ internal @ Tree @ internal @ Test name Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Receiving laboratory 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. 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. Distribution list Details of additional clinicians or organisations who require a copy of the test result. The 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information. Partial This is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified. Final The Test result is complete and verified by an authorised person. 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. Conclusion Narrative description of the key findings. For example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'. Requester order identifier The local identifier assigned by the requesting clinical system. Equivalent to the HL7 Placer Order Identifier. Receiver order identifier The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS). Assigning an identifier to a request by the Laboratory lnformation System (LIS) enables tracking progress of the request and enables linking results to requests. It also provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler Order Identifier. Specimen detail Details about the physical substance that has been analysed. If the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes. Laboratory internal identifier A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process. This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test. Overall test status The status of the laboratory test result as a whole. 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. Cancelled The result is unavailable because the test was not started or not completed (also sometimes called 'aborted'). Overall test status timestamp The date and/or time that ‘Overall test status’ was issued. Diagnostic service category The diagnostic service or discipline that is responsible for the laboratory test result. This is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible. Requester Details of the clinician or organisation requesting the laboratory test result. Test request details Details about the test request. In most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result. As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'. Test result Results of the test performed on the specimen(s). This SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure. Test diagnosis Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result. For example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'. Clinical information provided Description of clinical information available at the time of interpretation of results. This data element may include a link to the original clinical information provided in the test request. Comment Additional narrative about the test result not captured in other fields. Original test requested name Name of the original laboratory test requested. This data element is to be used when the test requested differs from the test actually performed by the laboratory. Registered The existence of the test is registered in the Laboratory Information System, but there is nothing yet available. Testing details Structured details about the method of analysis, device or interpretation used. For example: 'details of ELISA/nephelometry'. Point-of-care test 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. True if the test was performed directly at Point-of-Care (POCT). Tree @ internal @ Confounding factors Issues or circumstances that impact on the accurate interpretation of the measurement or test result. '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. Structured confounding factors Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result. For example: Last Normal Menstrual Period (LNMP). 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'. Entered in error The Test Result has been withdrawn following previous Final release. Extension Additional information required to capture local content or to align with other reference models/formalisms. For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents. Multimedia representation Digital image, video or diagram representing the test result. Multiple formats are allowed but they should represent equivalent clinical content. 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'. Preliminary Verified early results are available, but not all results are final. This is a sub-category of 'Partial'. Test method Description about the method used to perform the test. Coding with a terminology is desirable, where possible. Structured test diagnosis A structured or complex diagnosis for the laboratory test. For example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function. *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) Laboratorieresultat Resultat, inkludert funn og laboratoriets tolkning, av en laboratorieundersøkelse utført på prøvemateriale fra et individ eller relatert til individet. *Event Series(en) *@ internal @(en) Uspesifisert hendelse Standard, uspesifisert tidspunkt eller tidsintervall som kan defineres mer eksplisitt i en templat eller i en applikasjon. *Tree(en) *@ internal @(en) *Tree(en) *@ internal @(en) Undersøkelsesnavn Navn på laboratorieundersøkelsen som er utført på prøvematerialet. Undersøkelsesnavnet kan dekke ett enkelt resultat eller en gruppe av resultater. Undersøkelsesnavnet kan kodes med medisinsk kodeverk som for eksempel NLK (Norsk laboratoriekodeverk), LOINC, SNOMED CT eller lokale laboratoriekodeverk. Eksempler kan være "Glukose", "Elektrolytter", "Blodgass", "Differensialtelling", "Dyrkning", "Kortisol (morgen)" eller "histologi melanom". Navnet kan noen ganger inneholde typen prøvemateriale og/eller pasientstatus, for eksempel "fastende blodglukose" "Kalium i svette", eller inneholde annen informasjon, som "Kalium (PNA blodgass)". Ansvarlig laboratorium Detaljer om laboratoriet som mottok den opprinnelige rekvisisjonen og har det overordnede ansvaret for prøven, selv om det er andre laboratorier som utfører de enkelte analysene. Dette SLOTet er ment for detaljer om laboratoriet som mottok rekvisisjonen og har det overordnede ansvaret for å sende en svarrapport, selv om andre laboratorier utfører spesifikke deler av den. Det ansvarlige laboratoriet kan enten utføre undersøkelsene selv, eller videresende til andre laboratorier. Hvis et annet laboratorium har utført spesifikke undersøkelser bør informasjon om dette bli beskrevet i SLOTet "Detaljer om analyseresultat" i arketypen "Analyseresultat". "Ansvarlig laboratorium" kalles ofte "Tjenesteyter". Kopimottakere Detaljert informasjon knyttet til kliniker eller organisatorisk enhet som skal motta en kopi av laboratoriesvaret. Personene eller organisasjonene på distribusjonslisten mottar svaret kun til informasjon, og det er hovedmottakeren av rapporten som forventes å agere på den. Ufullstendig Dette er et delvis (dvs initalt, foreløpig eller preliminært) svar: Data i svaret kan være ukomplett eller ubekreftet. Endelig Svaret er komplett og er bekreftet av ansvarlig person. Revidert Svaret har blitt modifisert etter å ha vært i status "Endelig", og er komplett og verifisert av ansvarlig person, og svardata er endret. Konklusjon Fritekstbeskrivelse av de viktigste funnene. For eksempel "mønsteret indikerer betydelig nedsatt nyrefunksjon". Innholdet av konklusjonen vil variere, basert på hvilken undersøkelse som er utført. Konklusjonen bør være i overensstemmelse med kodene brukt i elementet "Diagnose". Rekvirentens rekvisisjonsID Rekvirentens/bestillers lokale ID for rekvisisjonen. Tilsvarende HL7 "Placer Order Identifier". Rekvisisjonsmottakers rekvisisjonsID Bestillingens/rekvisisjonens lokale identifikator/referansenummer tildelt av tjenesteyter/mottaker, som regel av LIMS. Når Laboratorieinformasjonssystemet (LIMS) tildeler en identifikator, åpnes det for sporing av fremdriften/prosessforløpet på bestillingen av undersøkelsen/rekvisisjonen og for å koble undersøkelsesresultatet til rekvisisjonen/bestillingen. Som regel tilsvarer dette HL7 "Filler Order Identifier". Denne identifikatoren kalles også ofte "rekvisisjonsnummer" eller "remissenummer". Prøvedetaljer Detaljer om den fysiske substansen som er analysert. Hvis prøvematerialet er tilstrekkelig spesifisert med en kode i analysenavnet er ikke dette dataelementet nødvendig. Det er mulig å koble svar med spesifikke prøver ved hjelp av elementene "ID for prøvemateriale" i både CLUSTER.specimen og de forskjellige CLUSTER-arketypene for laboratoriesvar. Laboratorieintern identifikator En lokal identifikator tildelt av det mottagende laboratoriesystemet (LIMS), for å kunne spore analyseprosessen. Denne identifikatoren er et internt sporingsnummer tildelt av LIMS, og det er ikke ment å være navnet på undersøkelsen. Overordnet resultatstatus Den overordnede statusen for hele laboratorieresultatet/prøven. Verdiene er valgt spesifikt for å samsvare med verdiene i HL7 FHIR-ressursen "Diagnostic report", som historisk sett kommer fra HL7 v2. Andre lokale koder eller termer kan brukes ved å bruke datatypen "Fri eller kodet tekst. Dette elementet kan repeteres for å understøtte bruksområdene der statuser for forskjellige aspekter av resultatet er delt opp i flere elementer. Et eksempel på dette er de norske standard labsvarmeldingene i HIS 1.4-standarden, der status for svaret og status for laboratorieprosessen håndteres separat. Kansellert Svaret er utilgjengelig fordi analysen ikke ble påbegynt eller ferdigstilt (også kalt "avbrutt"). Tidsangivelse for overordnet resultatstatus Tidspunktet for utstedelsen av "Overordnet resultatstatus". Laboratoriedisiplin Laboratoriefagområdet, -disiplinen eller subdisiplinen som er ansvarlig for resultatet. Dette er ikke ment for å gjenspeile laboratoriets interne organisering, men for å angi hvilken laboratoriedisiplin analysene tilhører. For eksempel patologi, immunologi og transfusjonsmedisin, medisinsk mikrobiologi, klinisk farmakologi, medisinsk genetikk og medisinsk biokjemi. Eventuelt enda mer findelte subkategorier eller subdisipliner som f.eks. hormoner/endokrinologi, hematologi, allergologi. Dette hjelper klinikere med å filtrere mellom resultatkategorier i henhold til lokalt oppsett. Koding med en terminologi er ønskelig, der det er mulig. Rekvirent Detaljert informasjon knyttet til kliniker eller organisatorisk enhet som har rekvirert/bestilt analysen. Rekvisisjonsdetaljer Detaljer knyttet til rekvisisjonen. I de fleste situasjoner finnes det én rekvisisjon og ett korresponderende svar, men under noen omstendigheter kan flere rekvisisjoner representeres ved hjelp av en enkelt laboratorieresultat-arketype. For eksempel kan en kliniker bestille "glukose" i en rekvisisjon og "urea og elektrolytter" i en ytterligere rekvisisjon, mens laboratoriet utfører begge analysene og sender en samlet rapport. Undersøkelsesresultat Resultat av undersøkelsen som er utført på prøvematerialet. Dette SLOTet kan inneholde resultat for ett enkelt analyseresultat, for en gruppe analyseresultater, eller for en mer kompleks og spesifikk struktur. Diagnose Enkeltord, frase eller kort beskrivelse som representerer den kliniske betydningen og signifikansen av laboratorieresultatet. For eksempel "Betydelig nedsatt leverfunksjon" eller "Salmonella". Koding med en terminologi foretrekkes, der det er mulig. Diagnosen bør være i overensstemmelse med teksten i "Konklusjon". Tilgjengelig klinisk informasjon Beskrivelse av klinisk informasjon som er tilgjengelig på tolkningstidspunktet. Dette dataelementet kan inkludere en lenke til den opprinnelige kliniske informasjonen som ble angitt i rekvisisjonen. Kommentar Tekstlig tilleggsinformasjon om analyseresultatet, som ikke er registrert i andre felt. Navn på opprinnelig rekvirert analyse Navn på undersøkelsen som opprinnelig ble rekvirert. Dette dataelementet er tenkt brukt dersom det er forskjell mellom undersøkelsen som er rekvirert og den som faktisk er utført. Registrert Analysen er registrert i laboratoriesystemet, men svaret er ikke tilgjengelig per nå. Undersøkelsesdetaljer Strukturert tilleggsinformasjon om hvilken analysemetode, utstyr eller tolkning som er benyttet. For eksempel "detaljer om ELISA/nefelometri". Pasientnær analysering Dette indikerer hvorvidt analysen ble utført gjennom pasientnær analysering (PNA) i stedet for en mer formell laboratorietjeneste. Sann dersom analysen ble utført ved pasientnær analysering (PNA). *Tree(en) *@ internal @(en) Konfunderende faktorer Forhold eller omstendigheter som påvirker tolkningen av laboratorieresultatet. "Konfunderende faktorer" bør være reservert for ukontrollerte eller uplanlagte forhold hos pasienten som kan påvirke tolkningen av laboratorieresultatet. For eksempel "nylig fysisk aktivitet", "nylig røykt tobakk". Kjente forutsetninger som "fastende" bør dokumenteres i elementet "Prøvetakingsforhold" i arketypen CLUSTER.specimen. I noen tilfeller er slike forutsetninger del av undersøkelsesnavnet, for eksempel "Fastende blodsukker". Kjente forhold knyttet til prøvetaking eller håndtering av prøven, som "langvarig stase" eller "hemolyse" (preanalytiske forhold) bør dokumenteres i elementet "Prøvekvalitet" i arketypen CLUSTER.specimen. Koding med en terminologi er ønskelig, der det er mulig. Strukturerte konfunderende faktorer Ytterligere detaljer om forhold i tilstand eller omstendigheter som kan påvirke tolkningen av laboratorieresultatet. For eksempel siste normale menstruasjonsperiode. Korrigert Svaret har blitt modifisert etter å ha vært i status "Endelig" og er komplett og verifisert. Dette er en underkategori til "Revidert". Feilregistrert Analysesvaret har blitt trukket tilbake etter å ha vært i status "Endelig". Tilleggsinformasjon Ytterligere informasjon som trengs for å kunne registrere lokalt definert innhold eller for å tilpasse til andre referansemodeller/formalismer. For eksempel lokale informasjonsbehov eller ytterligere metadata for å kunne tilpasse til tilsvarende konsepter i FHIR eller CIMI. Multimediarepresentasjon Digitalt bilde, video eller diagram som representerer analyseresultatet. Flere formater tillates, men innholdet i de forskjellige formatene må representere det samme innholdet. 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". Foreløpig Verifiserte tidlige svar er tilgjengelige, men ikke alle svar er endelige. Dette er en underkategori av "Ufullstendig". Undersøkelsesmetode Beskrivelse av metoden som ble brukt for å utføre undersøkelsen. Koding med en terminologi er ønskelig, der det er mulig. Strukturert diagnose En strukturert eller kompleks diagnose for laboratorieundersøkelsen. For eksempel patologidiagnoser bestående av flere forskjellige akser som morfologi, etiologi og funksjon. *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *Laboratory test result(en) *The result, including findings and interpretation, of a laboratory investigation performed on specimens from individuals or related materials(en) Event Series @ internal @ 任何事件 可以在模板之中或者在运行时加以明确定义的，默认的，未明示的时间点或时间区间事件。 Tree @ internal @ Tree @ internal @ *Test name(en) *Name of the laboratory investigation performed on the specimen(s). (en) *A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. (en) *Receiving laboratory(en) *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.(en) *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. (en) *Distribution list(en) *Details of additional clinicians or organisations who require a copy of the test result.(en) *The 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.(en) 部分 当前属于部分的（比如，初步的、暂时的或初级的）检验结果：检验结果之中的数据可能不完整或者未经核对。 最终 检验结果完整且经过授权人员的核对或者说审核。 *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) *Conclusion(en) *Narrative description of the key findings. (en) *For example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'. (en) *DiagnosticReport.conclusion(en) 申请方医嘱标识符 医嘱申请方赋予当前检验项目医嘱的本地标识符。 等价于HL7申请方医嘱标识符（ Placer Order Identifier）。 接收方医嘱标识符 医嘱执行方赋予当前检验项目医嘱的本地标识符。其中，医嘱执行方通常为实验室信息系统（ Laboratory Information System，LIS）。 实验室信息系统（ Laboratory Information System，LIS）为申请赋予标识符，便于实现对于申请进展情况的跟踪以及结果与相应申请的链接。同时，这也是有助于查询的一种参考信息，且通常等价于HL7执行方医嘱标识符（Filler Order Identifier）。 *Specimen detail(en) *Details about the physical substance that has been analysed, in the situation where all results in this test are derived from the same specimen.(en) *If the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. If there are multiple specimens, these may be represented per 'Result group'.(en) *Laboratory internal identifier(en) *A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process. (en) *This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test. (en) *Overall test status(en) *The status of the laboratory test result as a whole.(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'. 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. (en) 已撤销 当前结果不可用，因为该检验项目并未开始或者并未完成（有时又称为“取消”、“已中止”或“已放弃”）。 *Overall test status timestamp(en) *The date and/or time that ‘Overall test status’ was issued.(en) *Diagnostic service category(en) *The diagnostic service or discipline that is responsible for the laboratory test result. (en) *This is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible. (en) 申请方 关于申请当前实验室检验项目（结果）的临床医生或组织机构的详情。 *Test request details(en) *Details about the test request.(en) *In most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result. As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.(en) *Test result (en) *Results of the test performed on the specimen(s). (en) *This SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure. (en) *Test diagnosis(en) *Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result. (en) *For example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'. (en) *Clinical information provided(en) *Description of clinical information available at the time of interpretation of results.(en) *This data element may include a link to the original clinical information provided in the test request.(en) *DiagnosticReport.requestDetail.clinicalNotes(en) *Comment(en) *Additional narrative about the test result not captured in other fields.(en) *Original test requested name(en) *Name of the original laboratory test requested. (en) *This data element is to be used when the test requested differs from the test actually performed by the laboratory. (en) 已登记 表示当前检验项目的存在情况已在实验室信息系统之中进行了登记，但目前尚无任何可用信息。 *Testing details (en) *Structured details about the method of analysis, device or interpretation used.(en) *For example: 'details of ELISA/nephelometry'.(en) *Point-of-care test(en) *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.(en) *True if the test was performed directly at Point-of-Care (POCT).(en) Tree @ internal @ *Confounding factors(en) *Issues or circumstances that impact on the accurate interpretation of the measurement or test result.(en) *'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. (en) *Structured confounding factors (en) 可能会改变对于当前实验室检验项目的解释的，关于当前患者状态的详情。 *For example: Last Normal Menstrual Period (LNMP). (en) *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) 错误录入 当前检验结果在此前最终发布之后已被撤销。 扩展 允许进行扩展的槽位，用于支持本地化或与其他标准/参考模型之间进行协调统一。 *Multimedia representation(en) *Digital image, video or diagram representing the test result.(en) *Multiple formats are allowed but they should represent equivalent clinical content.(en) *DiagnosticReport.presentedForm(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) *Preliminary(en) *Verified early results are available, but not all results are final. This is a sub-category of 'Partial'.(en) *Test method (en) * *Coding with a terminology is desirable, where possible. (en) *Structured test diagnosis (en) *A structured or complex diagnosis for the laboratory test. (en) *For example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function. (en) *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) *Neues Element(en) **(en) UMG_Laborergebnis Das Ergebnis - einschließlich der Befunde und der Interpretation des Labors - einer Untersuchung, die an Proben durchgeführt wurde, die von einer Einzelperson stammen oder mit dieser Person zusammenhängen. Event Series @ internal @ Jedes Ereignis Jeder Zeitpunkt oder jedes Intervall, das in einem Template oder zur Laufzeit definiert werden kann. Tree @ internal @ Tree @ internal @ Labortest-Bezeichnung Name der Laboruntersuchung, die an der/den Probe(n) durchgeführt wurde. Ein Laborergebnis kann sich auf ein einzelnes Analyt oder eine Analytgruppe beziehen. Dazu zählen auch komplette Panel an Parametern. Es wird dringend empfohlen, die "Labortest-Bezeichnung" anhand einer Terminologie zu kodiereren, wie zum Beispiel LOINC oder SNOMED CT. Beispiel: "Glukose", "Harnstoff", "Abstrich", "Cortisol", "Leberbiopsie". Der Name kann u.U. auch das Probenmaterial oder den Patientenstatus (z.B. "Blutzuckerspiegel nüchtern") oder andere Informationen beinhalten wie "Kalium (Blutgas)". Labor, welches den Untersuchungsauftrag annimmt Angaben zu dem Labor, das die Anfrage erhalten hat und die Hauptverantwortung für die Verwaltung der Berichterstattung über den Test trägt, auch wenn andere Labore bestimmte Aspekte ausführen. Dieser Slot gibt die Details des Labors an, dass die Anforderung erhalten hat und die Gesamtverantwortung für die Berichterstellung des Tests trägt, selbst wenn andere Labore bestimmte Aspekte ausführen. Das Empfangslabor kann den Test entweder durchführen oder an ein anderes Labor verweisen. Wenn ein anderes Labor für die Durchführung der Tests mit bestimmten Analyten zuständig ist, ist zu erwarten, dass diese Details im SLOT 'Analyte result detail' innerhalb des Archetyps CLUSTER.laboratory_test_analyte enthalten sind. Verteilerliste Details über weitere Kliniker oder Organisationen, die eine Kopie der Analyseergebnisse benötigen. Die "Verteilerliste" dient nur zu Informationszwecken. Der Hauptempfänger des Berichts ist die Person, die dazu bestimmt ist, auf die Information zu reagieren. Teilweise Das Testergebnis ist als ein Teilergebnis (z.B. Initial, vorübergehend oder vorläufig) bestätigt: Daten im Testergebnis können unvollständig oder nicht verifiziert sein. Final Das Testergebnis ist vollständig und durch eine autorisierte Person bestätigt. Abgeändert Das Ergebnis wurde nach der Finalisierung modifiziert und ist vollständig von dem verantwortlichen Untersucher verifiziert. Die Ergebnisdaten wurden geändert. Schlussfolgerung Beschreibung der wichtigsten Ergebnisse. Zum Beispiel: "Das Muster lässt auf eine erhebliche Nierenfunktionsstörung schließen". Der Inhalt der Zusammenfassung unterscheidet sich je nach durchgeführter Untersuchung. Diese Zusammenfassung sollte mit der kodierten "Testdiagnose" übereinstimmen. Auftrags-ID des anfordernden/einsendenden Systems Lokale Auftrags-ID des anfordernden/einsendenden Systems. Äquivalent zur "HL7 Placer Order Identifier". Auftrags-ID (Empfänger) Lokale Auftrags-ID, die vom auftragsempfangendem System, gewöhnlich dem Laborinformationssystem (LIS) zugewiesen wird. Die Vergabe einer solchen ID ermöglicht das Nachverfolgen des Auftragsstatus und das Verlinken der Ergebnisse zum Auftrag. Es erlaubt auch das Verwalten von weiteren Erkundigungen und Nachfragen und ist äquivalent zum "HL7 Filler Order Identifier". Probendetail Angaben über die Beschaffenheit der analysierten Probe. Wenn der Probentyp mit einem Code in der Testbezeichnung ausreichend spezifiziert ist, sind diese zusätzlichen Daten nicht erforderlich. Die Verknüpfung von Ergebnissen mit bestimmten Proben kann sowohl in einem CLUSTER.Probe als auch in den verschiedenen CLUSTER Archetypen mit Hilfe von Elementen mit der Bezeichnung "Probe" dokumentiert werden. Laborinterne Kennzeichnung Eine lokale Kennung, die vom empfangenden Laborinformationssystem (LIS) vergeben wird, um den Testvorgang zu verfolgen. Diese Kennung ist eine vom LIS vergebene interne Trackingnummer und ist nicht als Bezeichnung für den Test gedacht. Gesamtteststatus Der Status des gesamten Laborprüfergebnisses. Die Werte wurden so ausgewählt, dass sie mit denen im HL7 FHIR Diagnosebericht übereinstimmen, der historisch aus der HL7v2Praxis stammt. Andere lokale Codes/Begriffe können über den Text "Auswahl" verwendet werden. Dieses Element kann mehrfach vorkommen, um Fälle abzudecken, bei denen der Status für verschiedene Aspekte des Ergebnisses in mehrere Elemente unterteilt wurde. Abgebrochen Das Ergebnis ist nicht verfügbar, weil der Test nicht gestartet oder nicht abgeschlossen wurde (manchmal auch als "gescheitert" bezeichnet). Zeitstempel des gesamten Teststatus Zeitpunkt an dem das Ergebnis für den oben genannten "Gesamtteststatus" ausgegeben wurde. Diagnostische Organisationseinheit Die diagnostische Organisationseinheit oder die Labordisziplin, die für das Laborergebnis verantwortlich ist. Dies soll eine allgemeine Kategorisierung sein und nicht den organisatorischen Namen des Labors erfassen. Zum Beispiel anatomische Pathologie, Immunologie und Transfusionsmedizin, medizinische Mikrobiologie, klinische Pharmakologie, medizinische Genetik, medizinische Biochemie. Alternativ noch granuläre Subkategorien, wie z.B. Hormone/Endokrinologie, Hämatologie, Autoantikörper, Allergologie. Diese Datenelemente helfen bei der Filterung nach breiten Kategorien von Ergebnissen gemäß den lokalen Gegebenheiten. Dieses Datenelement sollte, wenn möglich, mit einer Terminologie kodiert werden. Einsender Details über den Kliniker oder die Abteilung, die das Labortestergebnis angefordert hat. Details der Testanforderung Details zur Testanforderung. In den meisten Fällen gibt es eine Testanfrage und ein einzelnes entsprechendes Testergebnis. Jedoch ermöglicht dieser wiederholte Cluster die Situation, dass mehrere Testanfragen mit einem einzigen Testergebnis gemeldet werden können. Als Beispiel: "Ein Arzt fordert in einer Anfrage Blutzucker und in einer zweiten Anfrage Harnstoff/Elektrolyte an, aber das Laboranalysegerät führt beides durch und das Labor möchte diese zusammen melden". Testergebnis Ergebnisse der durchgeführten Untersuchungen an der/den Probe(n). Dieser SLOT kann einen einzelnen Analyt, eine Gruppe, ein Panel oder eine Reihe von mehreren Analyten oder eine komplexere und spezifischere Struktur tragen. Testdiagnose Kurze Beschreibung der klinischen Bedeutung und der Aussagekraft des Laborergebnisses. Zum Beispiel: "Schwere hepatische Beeinträchtigung", "Salmonellenbefall". Die Kodierung der Diagnose mit einer Terminologie, wird nach Möglichkeit dringend empfohlen. Die Diagnose soll zu der Beschreibung im Datenelement "Zusammenfassung" passen. Vorhandene klinische Information Beschreibung der klinischen Informationen, die zum Zeitpunkt der Auswertung der Ergebnisse verfügbar sind. Dieses Datenelement kann einen Link zu den ursprünglichen klinischen Informationen enthalten, die in der Testanforderung angegeben sind. Kommentar Weitere Informationen über das Laborergebnis, welche bisher nicht in den anderen Feldern erfasst wurden. Originaler Name der angeforderten Testung Name des ursprünglich angeforderten Tests. Dieses Datenelement ist zu verwenden, wenn die angeforderte Testung von der tatsächlich vom Labor durchgeführten Testung abweicht. Registriert Der Labortest wurde im Laborinformationssystem registriert, aber es ist derzeit noch nichts verfügbar. Test Details Strukturierte Details über die beim Labortest verwendete Methodik, das Gerät oder die Auswertung. Zum Beispiel: "Details der ELISA/Nephelometrie". Point-of-care Test Dies gibt an, ob der Test direkt am Point-of-Care (POCT) durchgeführt wurde, im Gegensatz zu einem formalen Ergebnis eines Labors oder einer anderen Dienstleistungsorganisation. Wahr, wenn der Test direkt am Point-of-Care (POCT) durchgeführt wurde. Tree @ internal @ Störfaktoren Probleme oder Umstände, die sich auf die genaue Interpretation der Messung oder des Testergebnisses auswirken. "Störfaktoren", die die Interpretation beeinflussen könnten wie z.B. "kürzliches Training" oder "neuer Tabakkonsum" sollten für unkontrollierte/ungeplante Probleme des Patientenzustands/ der Physiologie vorgesehen werden. Bekannte oder erforderliche Voraussetzungen, wie z.B. "Fasten", sollten im Element "Probenbedingungen" innerhalb des CLUSTER.Probe-Archetyps aufgeführt werden. In einigen Fällen werden Voraussetzungen als Teil des Testnamens erfasst, z.B. "Nüchternblutzucker". Bekannte Schwierigkeiten bei der Probenentnahme oder -behandlung, wie z.B. die "verlängerte Anwendung von Tourniquet" oder "hämolysierte Probe", sollten in den Elementen "Probenqualität" innerhalb des CLUSTER.Probe-Archetyps aufgeführt werden. Strukturierte Erfassung der Störfaktoren Einzelheiten zu Problemen oder Umständen, die sich auf die genaue Interpretation der Messung oder des Prüfergebnisses auswirken. Zum Beispiel: Letzte normale Menstruationsperiode (LNMP). Korrigiert Das Ergebnis wurde nach der Finalisierung modifiziert und ist vollständig vom verantwortlichen Untersucher verifiziert. Dies ist eine Unterkategorie von "Abgeändert". Irrtümlich eingegeben Das Testergebnis wurde nach der vorherigen Endfreigabe zurückgezogen. Erweiterung Weitere Informationen, die erforderlich sind, um lokale Inhalte abzubilden oder das Modell an andere Referenzmodelle anzupassen. Zum Beispiel: Lokaler Informationsbedarf oder zusätzliche Metadaten, um ein Mapping auf FHIR oder CIMI Modelle zu ermöglichen. Multimedia-Darstellung Bild, Video oder Diagramm zur Visualisierung des Testergebnisses. Mehrere Formate sind erlaubt - diese sollten aber einen äquivalenten klinischen Inhalt darstellen. Hinzugefügt Nach der endgültigen Fassung wurde der Bericht durch Hinzufügen neuer Inhalte aktualisiert. Der bestehende Inhalt bleibt unverändert. Dies ist eine Unterkategorie von "Abgeändert". Vorläufig Es sind erste, bestätigte Ergebnisse verfügbar, aber nicht alle Ergebnisse sind final. Dies ist eine Unterkategorie von "Teilweise". Testmethode Die Beschreibung der Methode, mit dem der Test durchgeführt wurde. Wenn möglich, ist eine Kodierung mit einer Terminologie wünschenswert. Strukturierte Testdiagnostik Eine strukturierte oder komplexe Diagnose für die Laboruntersuchung. Zum Beispiel: Anatomische Pathologiediagnosen, die aus mehreren verschiedenen Schwerpunkten wie Morphologie, Ätiologie und Funktion zusammengesetzt sind. 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. Dokumentationsdatum Zeitpunkt, an dem der Laborbefund dokumentiert wurde. Bezeichnung der Laborgruppe Bezeichnung der Laborgruppe Kode der Laborgruppe Kode der Laborgruppe