TEMPLATE Virologischer Befund (Virologischer Befund)

TEMPLATE IDVirologischer Befund
ConceptVirologischer Befund
DescriptionDas Template dient dazu einen virologischen PCR- oder Antigentest-Befund strukturiert abzubilden.
UseFür die Abbildung eines virologischen Befundes als PCR- oder Antigentest.
MisuseNicht zur Repräsentation von Laborbefunden anderer Bereiche wie der klinischen Chemie. Nicht zur Repräsentation von mikrobiologischen Befunden.
PurposeDas Template dient dazu einen virologischen PCR- oder Antigentest-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
Other Details (Language Independent)
  • MetaDataSet:Sample Set : Template metadata sample set
  • MD5-CAM-1.0.1: ff85e895093fe2257693b6ebe5920a4f
  • PARENT:MD5-CAM-1.0.1: 2A64B8463AA11FF22EA7977CDF0E9959
  • Original Language: ISO_639-1::de
  • Sem Ver: 1.0.0
KeywordsVirologischer Befund; PCR; Antigen; SARS-CoV-2; Corona; Virus; Befund; Nachweis
Language useden
Citeable Identifier1246.169.636
Root archetype idopenEHR-EHR-COMPOSITION.report-result.v1
Virologischer BefundVirologischer Befund: Document to communicate information to others about the result of a test or assessment.
Other Context
Bericht IDBericht ID: Identification information about the report.
StatusStatus: The status of the entire report. Note: This is not the status of any of the report components.
  • registered
  • partial
  • preliminary
  • final
  • amended
  • corrected
  • appended
  • cancelled
  • entered-in-error
  • unknown
  • [...]
Case identificationCase identification: To record case identification details for public health purposes.
Case identifierCase identifier: The identifier of this case.
BefundBefund: 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
Test nameTest name: 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: http://snomed.info/sct
  • Detection of virus (procedure) 

Annotations

  • 26436-6: laboratory
SpecimenSpecimen: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.
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}]
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/ic/probenart-virologischer-befund-snomedct

Annotations

  • Fhir Mapping: Specimen.type
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}]

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
Collection descriptionCollection description: Narrative description about the collection of the specimen.
Anatomical locationAnatomical location: A physical site on or within the human body.
Body site nameBody site name: Identification of a single physical site either on, or within, the human body.
This data element is the only mandated data point in this archetype and should be used as the primary data point to record an anatomical location with a commonly used name. It is strongly recommended that 'Body site name' be recorded as specifically as is anatomically possible. For example: record 'upper eyelid' rather than recording 'eyelid' with 'upper' as a qualifier; 'fifth rib' rather than 'rib' with a numeric qualifier. Use the other data elements for laterality, aspect, region and anatomical line to provide more detail. This data element should be coded with a terminology capable of triggering decision support, where possible - an appropriate termset for use here could comprise individual concepts or a list of precoordinated terms. Free text should be used only if there is no appropriate terminology available. If body site name is already identified in the parent archetype, then this data element may be redundant. Alternatively, a use case has been identified where the value may be duplicated into this element to support semantic querying using this archetype, rather than the data element within the parent.
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/ic/probenentnahmestelle-virologischer-befund-snomedct

Annotations

  • Not Limited: not limited to list
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.
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.
CommentComment: Additional narrative about the specimen not captured in other fields.
Optional[{fhir_mapping=Specimen.note}]

Annotations

  • Fhir Mapping: Specimen.note
Laboratory test panelLaboratory test panel: Laboratory test result as a panel/battery/profile structure common to clinical pathology testing.
Pro AnalytPro Analyt: The result of a laboratory test for a single analyte value.
Analyte result sequenceAnalyte result sequence: The intended position of this analyte result within the overall sequence of analyte results.
For example: '1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.
VirusnachweistestVirusnachweistest: 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}]
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=http://highmed.org/fhir/ValueSet/ic/sars-cov2-nachweistests-loinc

Annotations

  • Hl7V2 Mapping: OBX.3
  • Fhir Mapping: Observation.code
NachweisNachweis: 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}]
Value set: terminology://fhir.hl7.org/ValueSet/$expand?url=https://www.netzwerk-universitaetsmedizin.de/fhir/ValueSet/detected-not-detected-inconclusive
null_flavour
Quantitatives ErgebnisQuantitatives Ergebnis: 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}]
  •  Multimedia
  •  Quantity
  •  Count
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'.
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.

Annotations

  • GECCO: effectiveDateTime
null_flavour
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'.
Optional[{fhir_mapping=Observation.status, hl7v2_mapping=OBX.11}]
  •  Coded Text
    • Registered 
    • Partial 
    • Preliminary 
    • Final 
    • Amended 
    • Corrected 
    • Appended 
    • Cancelled 
    • Entered in error 
  •  Text

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
Zugehörige LaborprobeZugehörige Laborprobe: 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
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
CommentComment: Additional narrative about the test result not captured in other fields.
Protocol
EmpfängerstandortEmpfängerstandort: Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed.

Annotations

  • Fhir: Organization
TypeType: *

Annotations

  • Fhir: Organization.type
IdentifierIdentifier: A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university.

Annotations

  • Fhir: Organization.identifier
NameName: *

Annotations

  • Fhir: Organization.name
Active/InactiveActive/Inactive: *

Annotations

  • Fhir: Organization.active
Location descriptionLocation description: The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery.
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'.
AnforderungAnforderung: Name of the original laboratory test requested.
This data element is to be used when the test requested differs from the test actually performed by the laboratory.
Requester order identifierRequester order identifier: The local identifier assigned by the requesting clinical system.
Equivalent to the HL7 Placer Order Identifier.
  •  Identifier
  •  Text
Receiver order identifierReceiver order identifier: 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
EinsenderstandortEinsenderstandort: Location includes both casual locations (a place used for health care without prior designation or authorisation) and dedicated, formally designated locations. The sites can be private, public, mobile or fixed.

Annotations

  • Fhir: Organization
TypeType: *

Annotations

  • Fhir: Organization.type
IdentifierIdentifier: A group of buildings or other locations such as a site or campus. For example: Campus that is outside the facility, but belongs to the hospital, university.

Annotations

  • Fhir: Organization.identifier
NameName: *

Annotations

  • Fhir: Organization.name
Active/InactiveActive/Inactive: *

Annotations

  • Fhir: Organization.active
Location descriptionLocation description: The field contains the optional free text description of the location, e.g. thoracic, heart and vascular surgery.
Other contributorsSarah Ballout; Anneka Sargeant; Eugenia Rinaldi; Cora Drenkhahn; Infection Control Study Group