TEMPLATE Laborbefund (64677565-5ad3-4dc9-b12f-0e82cd28aee7)

TEMPLATE ID64677565-5ad3-4dc9-b12f-0e82cd28aee7
ConceptLaborbefund
DescriptionZur Repräsentation der Laboreregbnisse.
UseWird für unterschiedliche Laborwerte verwendet, um die Laborparameter zusammenzufassen.
MisuseNicht zur Repräsentation von sehr spezifischen Labordaten gedacht.
PurposeZur Repräsentation der Laboreregbnisse.
References
AuthorsSarah Ballout : MHH-Hannover
Other Details LanguageSarah Ballout : MHH-Hannover
OtherDetails Language Independent{MetaDataSet:Sample Set =MetaDataSet:Sample Set }
KeywordsLaborbefund; Befund; Labor; Untersuchungsbefund; Nachweis; Laborwerte; Laboruntersuchung; Laborparameter; Labordiagnostik; Laborergebnis
Language useden
Citeable Identifier1246.169.220
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  • Vorläufig
  • Final
  • Final korrigiert
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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_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.v0], code=at0000, itemType=CLUSTER, level=5, text=Probenmaterial, description=A physical sample for investigation, examination or analysis, collected from or related to an individual., comment=For example: Tissue, body fluid or food., 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]/content[openEHR-EHR-OBSERVATION.laboratory_test_result.v1]/data[at0001]/events[at0002]/data[at0003]/items[openEHR-EHR-CLUSTER.specimen.v0]/items[at0029], code=at0029, itemType=ELEMENT, level=6, text=Specimen type, description=The type of specimen., comment=For example: Venous blood, prostatic biopsy. 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_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.v0]/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., 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.v0]/items[at0034], code=at0034, itemType=ELEMENT, level=6, text=Laboreingangszeit, 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.v0]/items[at0079], code=at0079, itemType=ELEMENT, level=6, text=Collector comment, description=Additional narrative description about the collection of the specimen., comment=null, 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.v0]/items[at0087], code=at0087, itemType=ELEMENT, level=6, text=Source site, description=Identification of a simple source site from where the specimen was taken., comment=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.v0]/items[at0015], code=at0015, itemType=ELEMENT, level=6, text=Collection datetime, 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=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.v0]/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 would have a specific paraffin wax block as its parent specimen., uncommonOntologyItems=null, 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.v0]/items[at0045], code=at0045, itemType=ELEMENT, level=6, text=Comment, description=An narrative comment about the specimen., comment=null, 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[at0077], code=at0077, itemType=ELEMENT, level=5, text=Laborbereich, description=The diagnostic service or discipline that is responsible for the laboratory test result., comment=This is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible., 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.laboratory_test_analyte.v1], code=at0000, itemType=CLUSTER, level=5, text=Laboratory analyte result, description=The result of a laboratory test for a single analyte value., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, 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=Bezeichnung, 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={hl7v2_mapping=OBX.3, fhir_mapping=Observation.code}, 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]/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={hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8, fhir_mapping=Observation.value[x]}, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=
  •  Text
  •  Quantity
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  •  Identifier
  •  URI
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