- MetaDataSet:Sample Set : Template metadata sample set
- MD5-CAM-1.0.1: 37ecf95fdb32023a634af7bcb90a84d7
- PARENT:MD5-CAM-1.0.1: CD5C7EF669BF9300C4CE104319009B71
- Original Language: ISO_639-1::de
- Sem Ver: 7.2.0
- registered
- preliminary
- final
- amended
Annotations
- 26436-6: laboratory
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)'.
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/labreport-labtest-category
For example: Tissue or body fluid.
For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.
Optional[{fhir_mapping=Specimen.type}]
Terminology: http://terminology.hl7.org/CodeSystem/v2-0487
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://terminology.hl7.org/ValueSet/v2-0487
- ABS | Abscess
- PELVA | Abscess, Pelvic
- PERIA | Abscess, Perianal
- RECTA | Abscess, Rectal
- SCROA | Abscess, Scrotal
- SUBMA | Abscess, Submandibular
- SUBMX | Abscess, Submaxillary
- TSTES | Abscess, Testicular
- AIRS | Air Sample
- ALL | Allograft
- AMN | Amniotic fluid
- AMP | Amputation
- GASAN | Antrum, Gastric
- ASP | Aspirate
- ETA | Aspirate, Endotrach
- GASA | Aspirate, Gastric
- NGASP | Aspirate, Nasogastric
- TASP | Aspirate, Tracheal
- TTRA | Aspirate, Transtracheal
- AUTP | Autopsy
- BPH | Basophils
- BIFL | Bile Fluid
- BX | Biopsy
- GSPEC | Biopsy, Gastric
- SKBP | Biopsy, Skin
- ... +290
Annotations
- Fhir Mapping: Specimen.type
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
For example: 'Requester ID', 'Archive ID, 'Biobank ID'.
Optional[{fhir_mapping=Specimen.identifier}]
Annotations
- Fhir Mapping: Specimen.identifier
Optional[{fhir_mapping=Specimen.receivedTime}]
Annotations
- Fhir Mapping: Specimen.receivedTime
For example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible. If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.
For example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.
Optional[{fhir_mapping=Specimen.collection.method}]
Annotations
- Fhir Mapping: Specimen.collection.method
For example: 'wound on left calf', 'IV cannula right arm', 'right kidney'. Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.
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
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
For example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.
This element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.
Coded Text- Satisfactory
- Unsatisfactory - analysed
- Unsatisfactory - not analysed
Text
Optional[{fhir_mapping=Specimen.note}]
Annotations
- Fhir Mapping: Specimen.note
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.
Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}]
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/lab-tests-gecco
Annotations
- Hl7V2 Mapping: OBX.3
- Fhir Mapping: Observation.code
For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.
Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}]
- Text
Quantity
Annotations
- Hl7V2 Mapping: OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
- Fhir Mapping: Observation.value[x]
For example, 'within normal limits for age and sex'.
Terminology: http://terminology.hl7.org/CodeSystem/v3-ObservationInterpretation
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/observation-interpretation
- A | Abnormal
- HX | above high threshold
- AC | Anti-complementary substances present
- LX | below low threshold
- B | Better
- Carrier | Carrier
- CAR | Carrier
- AA | Critical abnormal
- HH | Critical high
- LL | Critical low
- TOX | Cytotoxic substance present
- DET | Detected
- E | Equivocal
- EXP | Expected
- _GeneticObservationInterpretation | GeneticObservationInterpretation
- H | High
- HM | Hold for Medical Review
- IND | Indeterminate
- IE | Insufficient evidence
- I | Intermediate
- OBX | Interpretation qualifiers in separate OBX segments
- L | Low
- MS | moderately susceptible
- NEG | Negative
- NCL | No CLSI defined breakpoint
- ... +32
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.
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 allows multiple occurrences to support use cases where more than one type of status need to be implemented.
Optional[{fhir_mapping=Observation.status, hl7v2_mapping=OBX.11}]
- Coded Text
- Registered
- Partial
- Preliminary
- Final
- Amended
- Corrected
- Appended
- Cancelled
- Entered in error
- Text
Annotations
- Hl7V2 Mapping: OBX.11
- Fhir Mapping: Observation.status
Optional[{fhir_mapping=Observation.issued, hl7v2_mapping=OBX.19}]
Annotations
- Hl7V2 Mapping: OBX.19
- Fhir Mapping: Observation.issued
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.
Identifier
URI
Optional[{fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}]
Annotations
- Hl7V2 Mapping: NTE.3
- Fhir Mapping: Observation.note
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'.
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'.
Equivalent to the HL7 Placer Order Identifier.
- Identifier
- Text