Generated Narrative: StructureDefinition openEHR-EHR-OBSERVATION.laboratory-test-result.v1 Name Flags Card. Type Description & Constraints OBSERVATION 0..* OBSERVATION Laboratory test result #xD; data HISTORY Event Series #xD; events 0..* EVENT Any event #xD; data ITEM_TREE Tree #xD; Slices for items Slice: Unordered, Closed by profile:$this #xD; items:at0005 ELEMENT Test name #xD; value DV_TEXT #xD; items:at0065 0..* CLUSTER Specimen detail #xD; items:at0073 0..* ELEMENT Overall test status #xD; Slices for value Slice: Unordered, Closed by type:$this #xD; value:DV_CODED_TEXT DV_CODED_TEXT Binding: Overall test status ValueSet (required) #xD; value:DV_TEXT DV_TEXT #xD; items:at0075 0..1 ELEMENT Overall test status timestamp #xD; value DV_DATE_TIME #xD; items:at0077 0..1 ELEMENT Diagnostic service category #xD; value DV_TEXT #xD; items:at0100 0..1 ELEMENT Clinical information provided #xD; value DV_TEXT #xD; items:at0097 0..* CLUSTER Test result #xD; items:at0057 0..1 ELEMENT Conclusion #xD; value DV_TEXT #xD; items:at0098 0..* ELEMENT Test diagnosis #xD; value DV_TEXT #xD; items:at0122 0..* CLUSTER Structured test diagnosis #xD; items:at0118 0..* CLUSTER Multimedia representation #xD; items:at0101 0..* ELEMENT Comment #xD; value DV_TEXT #xD; state ITEM_TREE Tree #xD; Slices for items Slice: Unordered, Closed by profile:$this #xD; items:at0113 0..* ELEMENT Confounding factors #xD; value DV_TEXT #xD; items:at0114 0..* CLUSTER Structured confounding factors #xD; protocol 0..1 ITEM_TREE Tree #xD; Slices for items 0..* ITEM The items comprising the `ITEM_TREE`. Slice: Unordered, Closed by profile:$this #xD; items:at0017 0..* CLUSTER Receiving laboratory #xD; items:at0068 0..1 ELEMENT Laboratory internal identifier #xD; Slices for value 0..1 DATA_VALUE Property representing leaf value object of `ELEMENT`. Slice: Unordered, Closed by type:$this #xD; value:DV_IDENTIFIER 0..1 DV_IDENTIFIER Property representing leaf value object of `ELEMENT`. #xD; value:DV_TEXT 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0094 0..* CLUSTER Test request details #xD; Slices for items 1..* ITEM Ordered list of items - `CLUSTER` or `ELEMENT` objects - under this `CLUSTER`. Slice: Unordered, Closed by profile:$this #xD; items:at0106 0..* ELEMENT Original test requested name #xD; value 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0062 0..1 ELEMENT Requester order identifier #xD; Slices for value 0..1 DATA_VALUE Property representing leaf value object of `ELEMENT`. Slice: Unordered, Closed by type:$this #xD; value:DV_IDENTIFIER 0..1 DV_IDENTIFIER Property representing leaf value object of `ELEMENT`. #xD; value:DV_TEXT 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0063 0..1 ELEMENT Receiver order identifier #xD; Slices for value 0..1 DATA_VALUE Property representing leaf value object of `ELEMENT`. Slice: Unordered, Closed by type:$this #xD; value:DV_IDENTIFIER 0..1 DV_IDENTIFIER Property representing leaf value object of `ELEMENT`. #xD; value:DV_TEXT 0..1 DV_TEXT Property representing leaf value object of `ELEMENT`. #xD; items:at0090 0..1 CLUSTER Requester #xD; items:at0035 0..* CLUSTER Distribution list #xD; items:at0111 0..1 ELEMENT Point-of-care test #xD; value 0..1 DV_BOOLEAN Property representing leaf value object of `ELEMENT`. #xD; items:at0121 0..1 ELEMENT Test method #xD; items:at0110 0..* CLUSTER Testing details #xD; items:at0117 0..* CLUSTER Extension #xD; Documentation for this format
Use to record the result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual. This is typically done in a laboratory, but may be done in other environments such as at the point of care. This archetype is intended to cover the result of a single ordered investigation where the specimen(s) are collected as a single procedure, and may include multiple analyte results or other components. Examples of this could include 'Full blood count', which would yield a separate analyte result for the count of each type of blood cell, or 'kidney biopsy non-neoplastic', which would yield findings from microscopy, immunohistochemistry and electron microscopy. This archetype has been designed to be a framework that will usually be extended with CLUSTER archetypes to enable appropriate recording of specific laboratory test result patterns. This includes, but is not limited to, tests for biochemistry, haematology, immunology and transfusion services etc and specific patterns for the unique requirements for microbiology and anatomical pathology. If the ordered tests or investigations do not commonly belong together in a named group or panel, each test result would normally be represented using separate instances of this archetype. There is, however, considerable variation in actual reporting/messaging practice and this archetype/related archetypes are designed to handle such variation. This archetype supports multiple approaches to recording of specimen, reflecting current practice which varies enormously. A Laboratory test result has a high degree of alignment to an HL7 FHIR Diagnostic Report resource. It is anticipated that one or more instances of this archetype, or archetype family, will be sent back to a requesting clinician within a laboratory report document comprising COMPOSITION.report_result archetype, or similar, and other relevant ENTRY archetypes. The recording of confounding factors may be inconsistent, often depending on the analysing laboratory and on clinical information sent by the requester. In the State section of the archetype there is a simple 'Confounding factors' data element that is optional and can be repeated as one way to record a variety of simple factors that need to be made explicit as they may influence interpretation of the results. If the confounding factors are more complex, it may be appropriate to create a local/shared CLUSTER archetype that can be nested in the 'Confounding factors details' SLOT. Note 1: Known or required pre-conditions, such as 'fasting' or 'Day 1 of menstrual cycle', should be reported in the 'Sampling conditions' data element in the CLUSTER.specimen archetype, nested within this OBSERVATION archetype. Note 2: Known issues with specimen collection or handling, such as 'sample haemolysed' or 'prolonged use of tourniquet' should be reported within 'Specimen quality' in the CLUSTER.specimen archetype, nested within this OBSERVATION archetype. Where 'reflex tests' are performed by the laboratory, these may be handled as per US/FHIR guidance (see https://www.hl7.org/fhir/2015may/uslabreport-guide.html) or other local policy. For example, one of the following ... 1. Record the reflex test results additional 'Test findings' within the same 'openEHR-EHR-OBSERVATION.laboratory_test_result' 2. Record the reflex test results as 'Test findings' within a new 'openEHR-EHR-OBSERVATION.laboratory_test_result' but refer to the original lab test request via 'Test request details'. 3. Record the reflex test results as 'Test findings' within a new 'openEHR-EHR-OBSERVATION.laboratory_test_result' but reference a new lab test request as well as the original lab test request via 'Test request details'.
To record the result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual. Misuse: Not to be used to record an Autopsy or a Forensic report, although tests on some specimens that are taken in such situations may be represented using this archetype. For these, additional or specialised archetypes will be required to represent the data. This archetype is suitable for representation of general laboratory test results, but not intended to cover full synoptic reports. For these, additional specialising archetypes are required to represent the data.
© openEHR Foundation. This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/.
The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
links.exists() implies links.empty().not()
Archetyped valid must satisfy exclusive conditions
is_archetype_root() xor archetype_details .empty()
Archetype node id valid must not be empty
Subject validity must satisfy conditional constraints
subject_is_self() implies subject.generating_type = “PARTY_SELF”
Other participations valid must be present
other_participations.exists() implies other_participations.empty().not()
Runtime name of this fragment, used to build runtime paths.
Runtime name of this fragment, used to build runtime paths. This is the term provided via a clinical application or batch process to name this EHR construct: its retention in the EHR faithfully preserves the original label by which this entry was known to end users.
Design-time archetype identifier of this node taken from its generating archetype; used to build archetype paths.
Design-time archetype identifier of this node taken from its generating archetype; used to build archetype paths. Always in the form of an at-code, e.g. `at0005`. This value enables a 'standardised' name for this node to be generated, by referring to the generating archetype local terminology. At an archetype root point, the value of this attribute is always the stringified form of the `_archetype_id_` found in the `_archetype_details_` object.
Optional globally unique object identifier for root points of archetyped structures.
Links to other archetyped structures (data whose root object inherits from `ARCHETYPED`, such as `ENTRY`, `SECTION` and so on).
Links to other archetyped structures (data whose root object inherits from `ARCHETYPED`, such as `ENTRY`, `SECTION` and so on). Links may be to structures in other compositions.
Details of archetyping used on this node.
Audit trail from non-openEHR system of original commit of information forming the content of this node, or from a conversion gateway which has synthesised this node.
Mandatory indicator of the localised language in which this Entry is written.
Mandatory indicator of the localised language in which this Entry is written. Coded from openEHR Code Set languages .
Name of character set in which text values in this Entry are encoded.
Name of character set in which text values in this Entry are encoded. Coded from openEHR Code Set character sets.
Identifier of externally held workflow engine data for this workflow execution, for this subject of care.
Id of human subject of this `ENTRY`, e.g.: * organ donor * foetus * a family member * another clinically relevant person.
Optional identification of provider of the information in this `ENTRY`, which might be: * the patient * a patient agent, e.
Optional identification of provider of the information in this `ENTRY`, which might be: * the patient * a patient agent, e.g. parent, guardian * the clinician * a device or software Generally only used when the recorder needs to make it explicit. Otherwise, Composition composer and other participants are assumed.
The items comprising the `ITEM_TREE`. Can include 0 or more `CLUSTERs` and/or 0 or more individual `ELEMENTs`.
Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.
Flavour of null value, e.g. `253|unknown|`, `271|no information|`, `272|masked|`, and `273|not applicable|`.
Property representing leaf value object of `ELEMENT`.
Property representing leaf value object of `ELEMENT`. In real data, any concrete subtype of `DATA_VALUE` can be used.
Optional specific reason for null value; if set, `_null_flavour_` must be set.
Optional specific reason for null value; if set, `_null_flavour_` must be set. Null reason may apply only to a minority of clinical data, commonly needed in reporting contexts.
Ordered list of items - `CLUSTER` or `ELEMENT` objects - under this `CLUSTER`.
Name of the original laboratory test requested.
The local identifier assigned by the requesting clinical system.
The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).
Details of the clinician or organisation requesting the laboratory test result.
Details of additional clinicians or organisations who require a copy of the test result.
This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.
Description about the method used to perform the test.
Structured details about the method of analysis, device or interpretation used.
Additional information required to capture local content or to align with other reference models/formalisms.
Optional external identifier of guideline creating this Entry if relevant.
The data of this observation, in the form of a history of values which may be of any complexity.
Optional recording of the state of subject of this observation during the observation process, in the form of a separate history of values which may be of any complexity.
Optional recording of the state of subject of this observation during the observation process, in the form of a separate history of values which may be of any complexity. State may also be recorded within the History of the data attribute.
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Name of the laboratory investigation performed on the specimen(s).
Details about the physical substance that has been analysed.
The status of the laboratory test result as a whole.
The date and/or time that ‘Overall test status’ was issued.
The diagnostic service or discipline that is responsible for the laboratory test result.
Description of clinical information available at the time of interpretation of results.
Results of the test performed on the specimen(s).
Narrative description of the key findings.
Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.
A structured or complex diagnosis for the laboratory test.
Digital image, video or diagram representing the test result.
Additional narrative about the test result not captured in other fields.
Issues or circumstances that impact on the accurate interpretation of the measurement or test result.
Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.