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
Other Details (Language Independent)
  • MetaDataSet:Sample Set : Template metadata sample set
  • MD5-CAM-1.0.1: 9738e00c6f305c10db88f401e4f9b68a
  • PARENT:MD5-CAM-1.0.1: 2A64B8463AA11FF22EA7977CDF0E9959
  • Original Language: ISO_639-1::de
KeywordsLaborbefund; Labor; Befund; Analyt
Language useden
Citeable Identifier1246.169.220
Root archetype idopenEHR-EHR-COMPOSITION.report-result.v1
LaborberichtLaborbericht: Document to communicate information to others about the result of a test or assessment.

Annotations

  • LOINC: 11502-2
Other Context
IDID: Identification information about the report.

Annotations

  • Fhir Mapping: DiagnosticReport.identifier
StatusStatus: The status of the entire report. Note: This is not the status of any of the report components.
Terminology: http://hl7.org/fhir/diagnostic-report-status
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/diagnostic-report-status
  • amended | Amended 
  • appended | Appended 
  • cancelled | Cancelled 
  • corrected | Corrected 
  • entered-in-error | Entered in Error 
  • final | Final 
  • partial | Partial 
  • preliminary | Preliminary 
  • registered | Registered 
  • unknown | Unknown 

Annotations

  • Fhir Mapping: DiagnosticReport.status
Case identificationCase identification: To record case identification details for public health purposes.
Case identifierCase identifier: The identifier of this case.
LaborbefundLaborbefund: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
Data
Any eventAny event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Labortest-KategorieLabortest-Kategorie: Name of the laboratory investigation performed on the specimen(s).
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)'.
Terminology: LOINC
  • laboratory 

Annotations

  • Fhir Mapping: DiagnosticReport.category
ProbenmaterialProbenmaterial: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.

Annotations

  • Fhir Mapping: Specimen
Specimen typeSpecimen type: The type of specimen.
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
Specimen descriptionSpecimen description: Narrative description about the specimen being examined.
For example: the color and viscosity of a liquid; the shape of a solid tissue; or a description of tissue fragments.
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 
Laboratory specimen identifierLaboratory specimen identifier: A unique identifier of the specimen, normally assigned by the laboratory.
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
External identifierExternal identifier: A unique identifier of the specimen, assigned by a party external to the laboratory.
For example: 'Requester ID', 'Archive ID, 'Biobank ID'.
Optional[{fhir_mapping=Specimen.identifier}]
  •  Identifier
  •  Text

Annotations

  • Fhir Mapping: Specimen.identifier
Date/time receivedDate/time received: The date and time that the sample was received at the laboratory.
Optional[{fhir_mapping=Specimen.receivedTime}]

Annotations

  • Fhir Mapping: Specimen.receivedTime
Sampling contextSampling context: The context in which the specimen is collected.
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.
Value set: terminology:v2.0916?subset=ValueSet/$expand?url=http://terminology.hl7.org/ValueSet/v2-0916

Annotations

  • Fhir Mapping: Specimen.collection.fastingStatus[x]
Collection methodCollection method: The method of collection used.
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
KörperstelleKörperstelle: Identification of the body site or other location from where the specimen is collected.
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.

Annotations

  • SNOMED: IsA 442083009
  • Fhir Mapping: Specimen.collection.bodySite
Collection date/timeCollection date/time: The date and time that collection has been ordered to take place or has taken place.
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

Annotations

  • Fhir Mapping: Specimen.collection.collected[x]
Specimen collector identifierSpecimen collector identifier: Identifier of the person or organisation responsible for collecting the specimen.
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
Parent specimen identifierParent specimen identifier: Unique identifier of the parent specimen, where the specimen is split into sub-samples.
For example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.

Annotations

  • Fhir Mapping: Specimen.parent
Adequacy for testingAdequacy for testing: Information about whether the specimen was adequate for testing.
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.
Terminology: http://hl7.org/fhir/specimen-status
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/specimen-status
  • available | Available 
  • entered-in-error | Entered in Error 
  • unavailable | Unavailable 
  • unsatisfactory | Unsatisfactory 

Annotations

  • Fhir Mapping: Specimen.status
CommentComment: Additional narrative about the specimen not captured in other fields.
Optional[{fhir_mapping=Specimen.note}]

Annotations

  • Fhir Mapping: Specimen.note
Pro LaboranalytPro Laboranalyt: The result of a laboratory test for a single analyte value.

Annotations

  • Fhir Mapping: DiagnosticReport.result
Analyte nameAnalyte name: The name of the analyte result.
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}]
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 
  • 104684-6 | 1,1-Dimethoxy-(9Z)octadecene (DMA 18:1) [Mass/volume] in DBS 
  • 104679-6 | 1,1-Dimethoxy-(9Z)octadecene (DMA 18:1) [Mass/volume] in Red Blood Cells 
  • 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 
  • 104682-0 | 1,1-Dimethoxyhexadecane (DMA 16:0) [Mass/volume] in DBS 
  • 104681-2 | 1,1-Dimethoxyhexadecane (DMA 16:0) [Mass/volume] in Red Blood Cells 
  • 74627-1 | 1,1-Dimethoxyhexadecane (DMA 16:0) [Moles/mass] in Red Blood Cells 
  • 104685-3 | 1,1-Dimethoxyhexadecane (DMA 16:0)/palmitate (C16:0) [Mass Ratio] in DBS 
  • 74624-8 | 1,1-Dimethoxyhexadecane (DMA 16:0)/palmitate (C16:0) [Mass Ratio] in Fibroblast 
  • 104677-0 | 1,1-Dimethoxyhexadecane (DMA 16:0)/palmitate (C16:0) [Mass Ratio] in Red Blood Cells 
  • 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 
  • 104683-8 | 1,1-Dimethoxyoctadecane (DMA 18:0) [Mass/volume] in DBS 
  • 104680-4 | 1,1-Dimethoxyoctadecane (DMA 18:0) [Mass/volume] in Red Blood Cells 
  • 74619-8 | 1,1-Dimethoxyoctadecane (DMA 18:0) [Moles/mass] in Red Blood Cells 
  • ... +58706 

Annotations

  • Hl7V2 Mapping: OBX.3
  • Fhir Mapping: Observation.code
MesswertMesswert: The value of the analyte result.
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}]
  •  Quantity
  •  Coded Text
  •  Text

Annotations

  • Hl7V2 Mapping: OBX.2, OBX.5, OBX.6, OBX.7, OBX.8
  • Fhir Mapping: Observation.value[x]
GeräteapplikationGeräteapplikation: An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.

Annotations

  • Fhir Mapping: Observation.device
Device nameDevice name: Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device.
This data element will capture the term, phrase or category used in clinical practice. For example: <brand name><machine> (XYZ Audiometer); <size> <brand name> <intravenous catheter> (14G Jelco IV catheter); or <brand name/type> <implant>. Coding with a terminology is desirable, where possible, although this may be local and depending on local supplies available.

Annotations

  • Fhir Mapping: Device.deviceName.name
TypeType: The category or kind of device.
Not applicable if a category is already recorded in 'Device name'. Example: if the 'Device' is named as a 'urinary catheter'; the 'Type' may be recorded as 'indwelling' or 'condom'.Coding with a terminology is desirable, where possible. This may include use of GTIN or EAN numbers.

Annotations

  • Fhir Mapping: Device.type
  • SNOMED: IsA 49062001
Unique device identifier (UDI)Unique device identifier (UDI): A numeric or alphanumeric string that is associated with this device within a given system.
Often fixed to the device as a barcode.

Annotations

  • Fhir Mapping: Device.identifier
ManufacturerManufacturer: Name of manufacturer.

Annotations

  • Fhir Mapping: Device.manufacturer
Serial numberSerial number: Number assigned by the manufacturer which can be found on the device, and should be specific to each device., its label, or accompanying packaging.

Annotations

  • Fhir Mapping: Device.serialNumber
Software versionSoftware version: Identification of the version of software being used in the medical device.
When the medical device is an actual software application, record the version of the software using this data element. When the medical device has multiple software applications embedded within it, record each software component in a separate CLUSTER archetype within the Components SLOT - either as a nested instance of another CLUSTER.device archetype or using a CLUSTER archetype designed specifically for recording software details (but not yet available at time of this archetype development).

Annotations

  • Fhir Mapping: Device.version.value
CommentComment: Additional narrative about the device not captured in other fields.

Annotations

  • Fhir Mapping: Device.note
InterpretationInterpretation: 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.
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 

Annotations

  • Fhir Mapping: Observation.interpretation
Test methodTest method: Description about the method used to perform the test on this analyte only.
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
  •  Text
  •  Coded Text

Annotations

  • Fhir Mapping: Observation.method
Validation timeValidation time: The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.
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.
Result statusResult status: The status of the analyte result value.
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}]
Terminology: http://hl7.org/fhir/observation-status
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://hl7.org/fhir/ValueSet/observation-status
  • amended | Amended 
  • cancelled | Cancelled 
  • corrected | Corrected 
  • entered-in-error | Entered in Error 
  • final | Final 
  • preliminary | Preliminary 
  • registered | Registered 
  • unknown | Unknown 

Annotations

  • Hl7V2 Mapping: OBX.11
  • Fhir Mapping: Observation.status
Result status timeResult status time: The date and time that the analyte result was issued for the recorded ‘Result status’.
Optional[{fhir_mapping=Observation.issued, hl7v2_mapping=OBX.19}]

Annotations

  • Hl7V2 Mapping: OBX.19
  • Fhir Mapping: Observation.issued
Probe IDProbe ID: Identification of the specimen used for the analyte result.
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

Annotations

  • Fhir Mapping: Observation.specimen
CommentComment: Additional narrative about the analyte result, not captured in other fields.
Optional[{fhir_mapping=Observation.note, hl7v2_mapping=NTE.3}]

Annotations

  • Hl7V2 Mapping: NTE.3
  • Fhir Mapping: Observation.note
ConclusionConclusion: Narrative description of the key findings.
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'.

Annotations

  • Fhir Mapping: DiagnosticReport.conclusion
Protocol
Test request detailsTest request details: Details about the test request.
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'.
Auftrags-ID des empfangenden SystemsAuftrags-ID des empfangenden Systems: The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).
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.
  •  Identifier
  •  Text

Annotations

  • Fhir Mapping: DiagnosticReport.basedOn