TEMPLATE KDS_Laborbericht (KDS_Laborbericht)

TEMPLATE IDKDS_Laborbericht
ConceptKDS_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
Other Details LanguageSarah Ballout : MHH-Hannover
OtherDetails Language Independent{MetaDataSet:Sample Set =Template metadata sample set, PARENT:MD5-CAM-1.0.1=075C04692C7FEB6DDCC2C90FBE5C9098, original_language=ISO_639-1::de, MD5-CAM-1.0.1=c07ae84fe799ab55111abd7497fc24c7}
KeywordsLaborbefund; Labor; Befund; Analyt
Language useden
Citeable Identifier1246.169.220
AllOperationalTemplate [rootArchetypeId=openEHR-EHR-COMPOSITION.report-result.v1, otherContributors=null, tshis=[ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1], code=at0000.1, itemType=COMPOSITION, level=0, text=Laborbericht, description=Document to communicate information to others about the result of a test or assessment., 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.report-result.v1]/context/other_context[at0001]/items[at0002], code=at0002, itemType=ELEMENT, level=2, text=Bericht ID, description=Identification information about the report., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/context/other_context[at0001]/items[at0005], code=at0005, itemType=ELEMENT, level=2, text=Status, description=The status of the entire report. Note: This is not the status of any of the report components., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=
  • registered
  • partial
  • preliminary
  • final
  • amended
  • corrected
  • appended
  • cancelled
  • entered-in-error
  • unknown
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0], code=at0000, itemType=CLUSTER, level=2, text=Case identification, description=To record case identification details for public health purposes., comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/context/other_context[at0001]/items[openEHR-EHR-CLUSTER.case_identification.v0]/items[at0001], code=at0001, itemType=ELEMENT, level=3, text=Case identifier, description=The identifier of this case., comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1], code=at0000, itemType=OBSERVATION, level=1, text=Laborbefund, 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.report-result.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.report-result.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..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, 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], 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.report-result.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Labortest-Kategorie, 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: 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
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://terminology.hl7.org/ValueSet/v2-0487
  • ABS | Abscess 
  • PELVA | Abscess, Pelvic 
  • PERIA | Abscess, Perianal 
  • RECTA | Abscess, Rectal 
  • SCROA | Abscess, Scrotal 
  • SUBMA | Abscess, Submandibular 
  • SUBMX | Abscess, Submaxillary 
  • TSTES | Abscess, Testicular 
  • AIRS | Air Sample 
  • ALL | Allograft 
  • AMN | Amniotic fluid 
  • AMP | Amputation 
  • GASAN | Antrum, Gastric 
  • ASP | Aspirate 
  • ETA | Aspirate, Endotrach 
  • GASA | Aspirate, Gastric 
  • NGASP | Aspirate, Nasogastric 
  • TASP | Aspirate, Tracheal 
  • TTRA | Aspirate, Transtracheal 
  • AUTP | Autopsy 
  • BPH | Basophils 
  • BIFL | Bile Fluid 
  • BX | Biopsy 
  • GSPEC | Biopsy, Gastric 
  • SKBP | Biopsy, Skin 
  • ... +290 
, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v1]/items[at0097], code=at0097, itemType=ELEMENT, level=6, text=Specimen description, description=Narrative description about the specimen being examined., comment=For example: the color and viscosity of a liquid; the shape of a solid tissue; or a description of tissue fragments., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: http://terminology.hl7.org/CodeSystem/v2-0493
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://terminology.hl7.org/ValueSet/v2-0493
  • AUT | Autolyzed 
  • CFU | Centrifuged 
  • CLOT | Clotted 
  • CON | Contaminated 
  • COOL | Cool 
  • FROZ | Frozen 
  • HEM | Hemolyzed 
  • LIVE | Live 
  • ROOM | Room temperature 
  • SNR | Sample not received 
, 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[at0001], code=at0001, itemType=ELEMENT, level=6, text=Laboratory specimen identifier, description=A unique identifier of the specimen, normally assigned by the laboratory., comment=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., uncommonOntologyItems={fhir_mapping=Specimen.accessionIdentifier}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, 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[at0088], code=at0088, itemType=ELEMENT, level=6, text=External identifier, description=A unique identifier of the specimen, assigned by a party external to the laboratory., comment=For example: 'Requester ID', 'Archive ID, 'Biobank ID'., uncommonOntologyItems={fhir_mapping=Specimen.identifier}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, 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[at0034], code=at0034, itemType=ELEMENT, level=6, text=Date/time received, description=The date and time that the sample was received at the laboratory., comment=null, uncommonOntologyItems={fhir_mapping=Specimen.receivedTime}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, 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[at0008], code=at0008, itemType=ELEMENT, level=6, text=Sampling context, description=The context in which the specimen is collected., comment=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., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, 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[at0007], code=at0007, itemType=ELEMENT, level=6, text=Collection method, description=The method of collection used., comment=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., uncommonOntologyItems={fhir_mapping=Specimen.collection.method}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, 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[at0087], code=at0087, itemType=ELEMENT, level=6, text=Körperstelle, description=Identification of the body site or other location from where the specimen is collected., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, 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[at0015], code=at0015, itemType=ELEMENT, level=6, text=Collection date/time, description=The date and time that collection has been ordered to take place or has taken place., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Date/Time
  •  Interval of Date/Time
, 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[at0070], code=at0070, itemType=ELEMENT, level=6, text=Specimen collector identifier, description=Identifier of the person or organisation responsible for collecting the specimen., comment=This element is intended to be used where the specimen has already been collected and the actual collector is known., uncommonOntologyItems={fhir_mapping=Specimen.collection.collector}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, 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[at0003], code=at0003, itemType=ELEMENT, level=6, text=Parent specimen identifier, description=Unique identifier of the parent specimen, where the specimen is split into sub-samples., comment=For example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, 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[at0041], code=at0041, itemType=ELEMENT, level=6, text=Adequacy for testing, description=Information about whether the specimen was adequate for testing., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_CODED_TEXT, bindings=null, values=Terminology: local http://hl7.org/fhir/specimen-status
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/specimen-status
  • Satisfactory 
  • Unsatisfactory - analysed 
  • Unsatisfactory - not analysed 
  • available | Available 
  • entered-in-error | Entered in Error 
  • unavailable | Unavailable 
  • unsatisfactory | Unsatisfactory 
, 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[at0045], code=at0045, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the specimen not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Specimen.note}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, 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.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=5, text=Pro Laboranalyt, description=The result of a laboratory test for a single analyte value., comment=null, 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.laboratory_test_analyte.v1]/items[at0024], code=at0024, itemType=ELEMENT, level=6, text=Analyte name, 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: http://loinc.org
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/uv/ips/ValueSet/results-laboratory-observations-uv-ips
  • 93418-2 | (8;8)(q13;q21)(HEY1,NCOA2) fusion transcript [Presence] in Tissue by Molecular genetics method 
  • 80628-1 | 1,1'-Sulfonylbis-2-Methylthioethane [Mass/volume] in Urine 
  • 38624-3 | 1,1,2-Trichloroethane [Mass/volume] in Air 
  • 38334-9 | 1,1,2-Trichloroethane [Mass/volume] in Water 
  • 38699-5 | 1,1-Dichloroethane [Mass/volume] in Air 
  • 38735-7 | 1,1-Dichloroethylene [Mass/volume] in Air 
  • 38292-9 | 1,1-Dichloroethylene [Mass/volume] in Water 
  • 74622-2 | 1,1-Dimethoxy-(9Z)octadecene (DMA 18:1) [Mass/mass] in Fibroblast 
  • 74623-0 | 1,1-Dimethoxy-(9Z)octadecene (DMA 18:1) [Moles/mass] in Red Blood Cells 
  • 74620-6 | 1,1-Dimethoxy-(9Z)octadecene (DMA 18:1)/Oleate (C18:1w9) [Mass Ratio] in Fibroblast 
  • 74621-4 | 1,1-Dimethoxy-(9Z)octadecene (DMA 18:1)/Oleate (C18:1w9) [Molar ratio] in Red Blood Cells 
  • 74626-3 | 1,1-Dimethoxyhexadecane (DMA 16:0) [Mass/mass] in Fibroblast 
  • 74627-1 | 1,1-Dimethoxyhexadecane (DMA 16:0) [Moles/mass] in Red Blood Cells 
  • 74624-8 | 1,1-Dimethoxyhexadecane (DMA 16:0)/palmitate (C16:0) [Mass Ratio] in Fibroblast 
  • 74625-5 | 1,1-Dimethoxyhexadecane (DMA 16:0)/palmitate (C16:0) [Molar ratio] in Red Blood Cells 
  • 74618-0 | 1,1-Dimethoxyoctadecane (DMA 18:0) [Mass/mass] in Fibroblast 
  • 74619-8 | 1,1-Dimethoxyoctadecane (DMA 18:0) [Moles/mass] in Red Blood Cells 
  • 74616-4 | 1,1-Dimethoxyoctadecane (DMA 18:0)/Octadecanoate (C18:0) [Mass Ratio] in Fibroblast 
  • 74617-2 | 1,1-Dimethoxyoctadecane (DMA 18:0)/Octadecanoate (C18:0) [Molar ratio] in Red Blood Cells 
  • 38688-8 | 1,1-Dimethylhydrazine [Mass/volume] in Air 
  • 80629-9 | 1,2,2-Trimethylpropyl methylphosphonate [Mass/volume] in Blood 
  • 54099-7 | 1,2,2-Trimethylpropyl methylphosphonate [Mass/volume] in Urine 
  • 28050-3 | 1,2,3-Trichlorobenzene [Mass/volume] in Serum or Plasma 
  • 38623-5 | 1,2,4-Trichlorobenzene [Mass/volume] in Air 
  • 28049-5 | 1,2,4-Trichlorobenzene [Mass/volume] in Serum or Plasma 
  • ... +55228 
, 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.laboratory_test_analyte.v1]/items[at0001], code=at0001, itemType=ELEMENT, level=6, text=Messwert, 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=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Quantity
  •  Coded TextValue set: external
  •  Text
, 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.laboratory_test_analyte.v1]/items[at0004], code=at0004, itemType=ELEMENT, level=6, text=Interpretation, description=Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range., comment=For example, 'within normal limits for age and sex'., uncommonOntologyItems=null, 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/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 
  • CAR | Carrier 
  • Carrier | 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 
, 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.laboratory_test_analyte.v1]/items[at0028], code=at0028, itemType=ELEMENT, level=6, text=Test method, description=Description about the method used to perform the test on this analyte only., comment=If the test method applies to an entire panel, the test method can be captured using the 'Test method' data element within the OBSERVATION.laboratory_test_result, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Coded TextValue set: external
, 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.laboratory_test_analyte.v1]/items[at0025], code=at0025, itemType=ELEMENT, level=6, text=Validation time, description=The date and time that the analyte result was validated in the laboratory by a healthcare practitioner., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, 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.laboratory_test_analyte.v1]/items[at0005], code=at0005, itemType=ELEMENT, level=6, 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_CODED_TEXT, bindings=null, values=Terminology: local http://hl7.org/fhir/observation-status
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/observation-status
  • Registered 
  • Partial 
  • Preliminary 
  • Final 
  • Amended 
  • Corrected 
  • Appended 
  • Cancelled 
  • Entered in error 
  • amended | Amended 
  • cancelled | Cancelled 
  • corrected | Corrected 
  • entered-in-error | Entered in Error 
  • final | Final 
  • preliminary | Preliminary 
  • registered | Registered 
  • unknown | Unknown 
, 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.laboratory_test_analyte.v1]/items[at0006], code=at0006, itemType=ELEMENT, level=6, text=Result status time, description=The date and time that the analyte result was issued for the recorded ‘Result status’., comment=null, uncommonOntologyItems={fhir_mapping=Observation.issued, hl7v2_mapping=OBX.19}, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, 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.laboratory_test_analyte.v1]/items[at0026], code=at0026, itemType=ELEMENT, level=6, text=Probe ID, description=Identification of the specimen used for the analyte result., comment=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., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Identifier
  •  URI
, 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.laboratory_test_analyte.v1]/items[at0003], code=at0003, itemType=ELEMENT, level=6, text=Comment, description=Additional narrative about the analyte result, not captured in other fields., comment=null, uncommonOntologyItems={fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, 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[at0057], code=at0057, itemType=ELEMENT, level=5, text=Conclusion, description=Narrative description of the key findings., comment=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'., uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=[openEHR-EHR-COMPOSITION.report-result.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.report-result.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.report-result.v1]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/protocol[at0004]/items[at0094]/items[at0063], code=at0063, itemType=ELEMENT, level=4, text=Identifikation der Laboranforderung, description=The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS)., comment=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., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Identifier
  •  Text
, extendedValues=null]], templateType=normal]