TEMPLATE KDS_Laborauftrag (KDS_Laborauftrag)

TEMPLATE IDKDS_Laborauftrag
ConceptKDS_Laborauftrag
DescriptionUm eine Laborleistung von einem Gesundheitsdienstleister oder einer Organisation für einen Patienten anzufordern.
UseVerwendung als Grundlage für eine Anfrage für eine Labordienstleistung für einen Patienten.
MisuseDarf nicht zur Darstellung der Anforderung von anderen Dienstleistungen außer Laboruntersuchungen verwendet werden.
PurposeUm eine Laborleistung von einem Gesundheitsdienstleister oder einer Organisation für einen Patienten anzufordern.
References
Authorsdate: 2020-09-17; name: test
Other Details Languagedate: 2020-09-17; name: test
Other Details (Language Independent)
  • MD5-CAM-1.0.1: ac853c23976797dc7662cb05988576e1
  • PARENT:MD5-CAM-1.0.1: B8AD0C7EB492491CE6F7968C1AFFB40C
  • Original Language: ISO_639-1::de
  • Sem Ver: 2.0.3
KeywordsLaborauftrag; Anfrage; Anforderung; Auftrag; Laborleistung; Laborauftrag; Laboranforderung
Language useden
Citeable Identifier1246.169.1118
Root archetype idopenEHR-EHR-COMPOSITION.request.v1
Request for serviceRequest for service: Document sent from one treating healthcare provider or organisation to another, for the purpose of requesting advice, a service or transfer of care.
Other Context
Case identificationCase identification: To record case identification details for public health purposes.
Case identifierCase identifier: The identifier of this case.

Annotations

  • FHIR Mapping: ServiceRequest.encounter
LaborleistungLaborleistung: Request for a health-related service or activity to be delivered by a clinician, organisation or agency.
Current ActivityCurrent Activity: Current Activity.
Description
Name der LaborleistungName der Laborleistung: The name of the service/s requested.
Coding of the 'Service name' with an external terminology is strongly recommended, if available. This data element allows multiple occurrences to enable the user to record a multiple services as part of a single request, if required.
Value set: terminology://fhir.hl7.org/terminology://fhir.hl7.org//ValueSet/$expand?url=http://loinc.org&filter=ORDER_OBS:in:Order,Both

Annotations

  • FHIR Mapping: ServiceRequest.code
Art der Laborleistung (Kategorie)Art der Laborleistung (Kategorie): Category of service requested.
Coding of the 'Service type' with an external terminology is desirable, if available. If the 'Service name' was coded, it is possible for this data point to be derived from the code.
Terminology: http://terminology.hl7.org/ValueSet/observation-category
  • Laboratory 

Annotations

  • FHIR Mapping: ServiceRequest.category
Clinical contextClinical context: Narrative information about the individual and their situation, providing relevant context for the request.

Annotations

  • Fhir Mapping: ServiceRequest.supportingInfo
IntentIntent: Description of the intended outcome of the request.
Coding of the 'Intent' with an external terminology is recommended, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required.
Terminology: http://hl7.org/fhir/request-intent
  • Order 

Annotations

  • FHIR Mapping: ServiceRequest.intent
SpecimenSpecimen: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.
Laboratory specimen identifierLaboratory specimen identifier: A unique identifier of the specimen, normally assigned by the laboratory.
Sometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.
Optional[{fhir_mapping=Specimen.accessionIdentifier}]

Annotations

  • Fhir Mapping: Specimen.accessionIdentifier
Collection date/timeCollection date/time: The date and time that collection has been ordered to take place or has taken place.
This datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.
  •  Date/Time
  •  Interval of Date/Time

Annotations

  • Fhir Mapping: ServiceRequest.Specimen.collection.collected
Specimen collector identifierSpecimen collector identifier: Identifier of the person or organisation responsible for collecting the specimen.
This element is intended to be used where the specimen has already been collected and the actual collector is known.
Optional[{fhir_mapping=Specimen.collection.collector}]

Annotations

  • Fhir Mapping: Specimen.collection.collector
CommentComment: Additional narrative about the service request not captured in other fields.

Annotations

  • Fhir Mapping: ServiceRequest.note
Protocol
Auftrags-ID des anfordernden/einsendenden Systems (PLAC)Auftrags-ID des anfordernden/einsendenden Systems (PLAC): The local identifier assigned by the requesting clinical system.
Usually equivalent to the HL7 Placer Order Identifier.

Annotations

  • FHIR Mapping: ServiceRequest.identifier
EinsenderEinsender: An entity comprising one or more people and having a particular purpose.
For example: a company, institution, association, network, department, community group, healthcare practice group, payer/insurer, care team, or a group of neighbours who provide care or support.
Auftrags-ID des empfangenden Systems (FILL)Auftrags-ID des empfangenden Systems (FILL): The local identifier assigned to the request by the clinician or organisation receiving the request for service.
Usually equivalent to the HL7 Filler Order Identifier.
  •  Text
  •  Identifier
Request statusRequest status: The status of the request for service as indicated by the requester.
Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. Coding with a terminology is preferred, where possible.
Terminology: http://hl7.org/fhir/ValueSet/request-status
  • Completed 

Annotations

  • FHIR Mapping: ServiceRequest.status