TEMPLATE ELISE_Laborbericht (ELISE_Laborbericht)

TEMPLATE IDELISE_Laborbericht
ConceptELISE_Laborbericht
DescriptionZur Repräsentation von Laborbefunden entsprechend des in der Medizininformatik-Initiative abgestimmten Basismoduls Labor.
UseFür die Repräsentation eines Laborbefundes
MisuseNicht zur Repräsentation von Ergebnissen spezieller Laboruntersuchungen, z.B. mikrobiologischer Befunde. Nicht zur Repräsentation von Informationen zum zugehörigen Laborauftrag.
PurposeZur Repräsentation von Laborbefunden entsprechend des in der Medizininformatik-Initiative abgestimmten Basismoduls Labor.
References
AuthorsSarah Ballout : MHH-Hannover; name: Louisa Bode; organisation: Medical School Hanover; email: bode.louisa@mh-hannover.de; date: 2021-02-22
Other Details LanguageSarah Ballout : MHH-Hannover; name: Louisa Bode; organisation: Medical School Hanover; email: bode.louisa@mh-hannover.de; date: 2021-02-22
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set, PARENT:MD5-CAM-1.0.1=2A64B8463AA11FF22EA7977CDF0E9959, original_language=ISO_639-1::de, MD5-CAM-1.0.1=510ca9a22b5d084e90d8cb23ad879709, build_uid=09047533-03fe-4428-b2dd-584b2511bb1e}
KeywordsLaborbefund; Labor; Befund; Analyt
Language useden
Citeable Identifier1246.169.1671
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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: LOINC
  • laboratory 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1], code=at0000, itemType=CLUSTER, level=5, text=Probenmaterial, description=A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis., comment=For example: Tissue or body fluid., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0029], code=at0029, itemType=ELEMENT, level=6, text=Specimen type, description=The type of specimen., comment=For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible., uncommonOntologyItems={fhir_mapping=Specimen.type}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://terminology.hl7.org/CodeSystem/v2-0487
  • Abscess 
  • Tissue, Acne 
  • Fluid, Acne 
  • Air Sample 
  • Allograft 
  • Amniotic fluid 
  • Amputation 
  • Catheter Tip, Angio 
  • Catheter Tip, Arterial 
  • Serum, Acute 
  • Aspirate 
  • Environment, Attest 
  • Environmental, Autoclave Ampule 
  • Environmental, Autoclave Capsule 
  • Autopsy 
  • Blood bag 
  • Cyst, Baker's 
  • Whole body 
  • Bile Fluid 
  • Bite 
  • Whole blood 
  • Blood arterial 
  • Cord blood 
  • Blood venous 
  • Bleb 
  • Blister 
  • Boil 
  • Bone 
  • Bone 
  • Bowel contents 
  • Basophils 
  • Blood product unit 
  • Burn 
  • Brush 
  • Breath (use EXHLD) 
  • Brushing 
  • Bubo 
  • Bulla/Bullae 
  • Biopsy 
  • Calculus (=Stone) 
  • Carbuncle 
  • Catheter 
  • Bite, Cat 
  • Cardiac muscle 
  • Clippings 
  • Conjunctiva 
  • Cannula 
  • Colostrum 
  • Biospy, Cone 
  • Scratch, Cat 
  • Serum, Convalescent 
  • Cerebral spinal fluid 
  • Catheter Insertion Site 
  • Fluid, Cystostomy Tube 
  • Fluid, Cyst 
  • Blood, Cell Saver 
  • Catheter tip 
  • Curretage 
  • Cervical Mucus 
  • Site, CVP 
  • Catheter Tip, CVP 
  • Nodule, Cystic 
  • Cyst 
  • Bite, Dog 
  • Sputum, Deep Cough 
  • Ulcer, Decubitus 
  • Environmental, Water (Deionized) 
  • Dialysate 
  • Dialysis Fluid 
  • Discharge 
  • Diverticulum 
  • Drain 
  • Drainage, Tube 
  • Drainage, Penrose 
  • Duodenal fluid 
  • Ear wax (cerumen) 
  • Brush, Esophageal 
  • Environmental, Eye Wash 
  • Environmental, Effluent 
  • Effusion 
  • Environmental, Food 
  • Environmental, Isolette 
  • Electrode 
  • Environmental, Unidentified Substance 
  • Eosinophils 
  • Environmental, Other Substance 
  • Environmental, Soil 
  • Environmental, Solution (Sterile) 
  • Aspirate, Endotrach 
  • Catheter Tip, Endotracheal 
  • Tube, Endotracheal 
  • Environmental, Whirlpool 
  • Gas, exhaled (=breath) 
  • Shunt, External 
  • Exudate 
  • Environmental, Water (Well) 
  • Blood, Fetal 
  • Fluid, Abdomen 
  • Fibroblasts 
  • Fistula 
  • Fluid, Other 
  • Filter 
  • Fluid, Body unsp 
  • Fluid 
  • Catheter Tip, Foley 
  • Fluid, Respiratory 
  • Scalp, Fetal 
  • Furuncle 
  • Gas 
  • Aspirate, Gastric 
  • Antrum, Gastric 
  • Brushing, Gastric 
  • Drainage, Gastric 
  • Fluid/contents, Gastric 
  • Genital lochia 
  • Genital vaginal 
  • Graft 
  • Graft Site 
  • Granuloma 
  • Catheter, Groshong 
  • Solution, Gastrostomy 
  • Biopsy, Gastric 
  • Tube, Gastric 
  • Drainage Tube, Drainage (Gastrostomy) 
  • Hair 
  • Bite, Human 
  • Blood, Autopsy 
  • Catheter Tip, Hemaquit 
  • Catheter Tip, Hemovac 
  • Tissue, Herniated 
  • Drain, Hemovac 
  • Catheter, Hickman 
  • Fluid, Hydrocele 
  • Bite, Insect 
  • Cyst, Inclusion 
  • Catheter Tip, Indwelling 
  • Gas, Inhaled 
  • Drainage, Ileostomy 
  • Source of Specimen Is Illegible 
  • Implant 
  • Site, Incision/Surgical 
  • Infiltrate 
  • Insect 
  • Catheter Tip, Introducer 
  • Isolate 
  • Intubation tube 
  • Intrauterine Device 
  • Catheter Tip, IV 
  • Fluid, IV 
  • Tubing Tip, IV 
  • Drainage, Jejunal 
  • Fluid, Joint 
  • Drainage, Jackson Pratt 
  • Lavage 
  • Fluid, Kidney 
  • Lavage, Bronhial 
  • Lavage, Gastric 
  • Lavage, Peritoneal 
  • Lavage, Pre-Bronch 
  • Contact Lens 
  • Contact Lens Case 
  • Lesion 
  • Liquid, Unspecified 
  • Liquid, Other 
  • Line arterial 
  • Line venous 
  • Fluid, Lumbar Sac 
  • Lymphocytes 
  • Macrophages 
  • Catheter Tip, Makurkour 
  • Marrow 
  • Mass 
  • Blood, Menstrual 
  • Meconium 
  • Breast milk 
  • Milk 
  • Mucosa 
  • Mucus 
  • Nail 
  • Drainage, Nasal 
  • Needle 
  • Site, Nephrostomy 
  • Aspirate, Nasogastric 
  • Drainage, Nasogastric 
  • Site, Naso/Gastric 
  • Nodule(s) 
  • Secretion, Nasal 
  • Other 
  • Lesion, Oral 
  • Source, Other 
  • Pacemaker 
  • Pancreatic fluid 
  • Fluid, Pericardial 
  • Site, Peritoneal Dialysis 
  • Site, Peritoneal Dialysis Tunnel 
  • Abscess, Pelvic 
  • Lesion, Penile 
  • Abscess, Perianal 
  • Cyst, Pilonidal 
  • Site, Pin 
  • Site, Pacemaker Insetion 
  • Plant Material 
  • Plasma 
  • Plasma bag 
  • Placenta 
  • Serum, Peak Level 
  • Pleural fluid (thoracentesis fluid) 
  • Polymorphonuclear neutrophils 
  • Drainage, Penile 
  • Polyps 
  • Graft Site, Popliteal 
  • Graft, Popliteal 
  • Site, Popliteal Vein 
  • Catheter, Porta 
  • Plasma, Platelet poor 
  • Prosthetic Device 
  • Plasma, Platelet rich 
  • Pseudocyst 
  • Wound, Puncture 
  • Pus 
  • Pustule 
  • Pus 
  • Quality Control 
  • Urine, Random 
  • Erythrocytes 
  • Bite, Reptile 
  • Drainage, Rectal 
  • Abscess, Rectal 
  • Cyst, Renal 
  • Fluid, Renal Cyst 
  • Respiratory 
  • Saliva 
  • Tissue, Keloid (Scar) 
  • Catheter Tip, Subclavian 
  • Abscess, Scrotal 
  • Secretion(s) 
  • Serum 
  • Site, Shunt 
  • Fluid, Shunt 
  • Shunt 
  • Site 
  • Biopsy, Skin 
  • Skin 
  • Mass, Sub-Mandibular 
  • Seminal fluid 
  • Fluid, synovial (Joint fluid) 
  • Spermatozoa 
  • Catheter Tip, Suprapubic 
  • Cathether Tip, Suprapubic 
  • Environmental, Spore Strip 
  • Sputum 
  • Sputum - coughed 
  • Sputum - tracheal aspirate 
  • Sputum, Simulated 
  • Sputum, Inducted 
  • Sputum, Spontaneous 
  • Environmental, Sterrad 
  • Stool = Fecal 
  • Stone, Kidney 
  • Abscess, Submandibular 
  • Abscess, Submaxillary 
  • Drainage, Sump 
  • Suprapubic Tap 
  • Suture 
  • Catheter Tip, Swan Gantz 
  • Sweat 
  • Aspirate, Tracheal 
  • Tears 
  • Thrombocyte (platelet) 
  • Tissue 
  • Tissue ulcer 
  • Cathether Tip, Triple Lumen 
  • Site, Tracheostomy 
  • Transudate 
  • Serum, Trough 
  • Abscess, Testicular 
  • Aspirate, Transtracheal 
  • Tubes 
  • Tumor 
  • Smear, Tzanck 
  • Source, Unidentified 
  • Unknown Medicine 
  • Urine 
  • Urine clean catch 
  • Urine, Bladder Washings 
  • Urine, Catheterized 
  • Urine, Midstream 
  • Urine, Nephrostomy 
  • Urine, Pedibag 
  • Urine sediment 
  • Urine catheter 
  • Urine, Cystoscopy 
  • Source, Unspecified 
  • Unkown substance 
  • Catheter Tip, Vas 
  • Catheter Tip, Ventricular 
  • Vitreous Fluid 
  • Vomitus 
  • Wash 
  • Washing, e.g. bronchial washing 
  • Water 
  • Blood, Whole 
  • Leukocytes 
  • Wen 
  • Wick 
  • Wound 
  • Wound abscess 
  • Wound drainage 
  • Wound exudate 
  • Worm 
  • Wart 
  • Environmental, Water 
  • Environmental, Water (Ocean) 
  • Environmental, Water (Tap) 
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  •  Date/Time
  •  Interval of Date/Time
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  •  Quantity
  •  Coded TextValue set: external
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  •  Text
  •  Coded TextValue set: external
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