TEMPLATE GECCO_Serologischer Befund (GECCO_Serologischer Befund)

TEMPLATE IDGECCO_Serologischer Befund
ConceptGECCO_Serologischer Befund
DescriptionDas Template dient dazu einen serologischen Befund strukturiert abzubilden.
UseFür die Abbildung eines serologischen Befundes.
MisuseNicht zur Repräsentation von Laborbefunden anderer Bereiche wie der klinischen Chemie. Nicht zur Repräsentation von mikrobiologischen Befunden. Nicht zur Repräsentation von virologischen Befunden (PCR, Antigen, ...).
PurposeDas Template dient dazu einen serologischen Befund strukturiert abzubilden.
References
Authorsname: Antje Wulff; organisation: Peter L. Reichertz Institut für Medizinische Informatik; email: antje.wulff@plri.de
Other Details Languagename: Antje Wulff; organisation: Peter L. Reichertz Institut für Medizinische Informatik; email: antje.wulff@plri.de
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set, PARENT:MD5-CAM-1.0.1=CD5C7EF669BF9300C4CE104319009B71, original_language=ISO_639-1::de, MD5-CAM-1.0.1=974d7272720cbddd09296baa5d2efecf, sem_ver=1.0.0}
KeywordsSerologischer Befund; Antibodies; Antikörper
Language useden
Citeable Identifier1246.169.1516
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.registereintrag.v1, otherContributors=Sarah Ballout; Anneka Sargeant; Eugenia Rinaldi; Cora Drenkhahn; Infection Control Study Group, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1], code=at0000, itemType=COMPOSITION, level=0, text=GECCO_Serologischer Befund, description=Generic compilation to represent a data set for research purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=COMPOSITION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=null, code=null, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=1, text=Other Context, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/context/other_context[at0001]/items[at0004], code=at0004, itemType=ELEMENT, level=2, text=Status, description=Status of the supplied data for the register entry. Note: This is not the status of individual components., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=
  • registered 
  • preliminary 
  • final 
  • amended 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/context/other_context[at0001]/items[at0005 and name/value='Kategorie'], code=at0005, itemType=ELEMENT, level=2, text=Kategorie, description=The classification of the register entry (e.g. type of observation of the FHIR profile)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://terminology.hl7.org/CodeSystem/observation-category
  • Laboratory 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/context/other_context[at0001]/items[at0005 and name/value='Kategorie (LOINC)'], code=at0005, itemType=ELEMENT, level=2, text=Kategorie (LOINC), description=The classification of the register entry (e.g. type of observation of the FHIR profile)., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: LOINC
  • Laboratory studies (set) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1], code=at0000, itemType=OBSERVATION, level=1, text=Befund, description=The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=OBSERVATION, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001], code=at0001, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002], code=at0002, itemType=EVENT, level=3, text=Any event, description=Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=4, text=Data, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Test name, description=Name of the laboratory investigation performed on the specimen(s)., comment=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)'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED CT
  • Serologic test (procedure) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0], code=at0000, itemType=CLUSTER, level=5, text=Laboratory test panel, description=Laboratory test result as a panel/battery/profile structure common to clinical pathology testing., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=6, text=Pro Analyt, description=The result of a laboratory test for a single analyte value., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=7, text=Virusnachweistest, description=The name of the analyte result., comment=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., uncommonOntologyItems={fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: LOINC
  • SARS-CoV-2 (COVID-19) Ab [Units/volume] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) Ab [Presence] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgA Ab [Units/volume] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgA Ab [Presence] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgG Ab [Units/volume] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgG Ab [Presence] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgM Ab [Units/volume] in Serum or Plasma by Immunoassay 
  • SARS-CoV-2 (COVID-19) IgM Ab [Presence] in Serum or Plasma by Immunoassay 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001 and name/value='Nachweis'], code=at0001, itemType=ELEMENT, level=7, text=Nachweis, description=The value of the analyte result., comment=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., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: SNOMED Clinical Terms
  • Detected (qualifier value) 
  • Not detected (qualifier value) 
  • Inconclusive (qualifier value) 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001 and name/value='Nachweis']/null_flavour, code=null, itemType=EXPOSED_RM_ATTRIBUTE, level=8, text=null_flavour, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0001 and name/value='Quantitatives Ergebnis'], code=at0001, itemType=ELEMENT, level=7, text=Quantitatives Ergebnis, description=The value of the analyte result., comment=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., uncommonOntologyItems={fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ANY, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.laboratory_test_panel.v0]/items[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=7, text=Result status, description=The status of the analyte result value., comment=The values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'. This element allows multiple occurrences to support use cases where more than one type of status need to be implemented., uncommonOntologyItems={fhir_mapping=Observation.status, hl7v2_mapping=OBX.11}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • registered
  • preliminary
  • final
  • amended
  • corrected
  • cancelled
  • entered-in-error
  • unknown
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004], code=at0004, itemType=UNSUPPORTEDTOPLEVELATTRIBUTE, level=2, text=Protocol, description=, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=UNSUPPORTEDTOPLEVELATTRIBUTE, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0094], code=at0094, itemType=CLUSTER, level=3, text=Test request details, description=Details about the test request., comment=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'., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.registereintrag.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0094]/items[at0106], code=at0106, itemType=ELEMENT, level=4, text=Anforderung, description=Name of the original laboratory test requested., comment=This data element is to be used when the test requested differs from the test actually performed by the laboratory., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: LOINC
  • SARS-CoV-2 (COVID-19) Ab panel - Serum or Plasma by Immunoassay 
, extendedValues=null]], templateType=normal]