ARCHETYPE Laboratory test (openEHR-EHR-ACTION.laboratory_test.v0)

ARCHETYPE IDopenEHR-EHR-ACTION.laboratory_test.v0
ConceptLaboratory test
DescriptionA clinical laboratory or point-of-care test carried out on a biological sample for screening or diagnostic purposes.
UseUse to record information about the activities required to carry out a laboratory test, including the planning, scheduling, performance, suspension, cancellation, documentation and completion. This is done by the recording of data against specific activities, as defined by the 'Pathway' careflow steps in this archetype. The scope of this archetype encompasses activities for a broad range of clinical laboratory tests performed for screening or diagnostic purposes. Additional structured and detailed information about the laboratory test can be captured using purpose-specific archetypes inserted into the 'Test detail' slot, where required. Timings related to a laboratory test can be managed in one of two ways: - Using the reference model - the time for performance of any pathway step will use the ACTION time attribute for each step. - Archetyped data elements: --- the 'Scheduled date/time' data element is intended to record the precise time when the laboratory test is planned. Note: the corresponding ACTION time attribute for the Scheduled pathway step will record the time that the laboratory test was scheduled into a system, not the intended date/time on which the laboratory test is intended to be carried out; and --- the 'Final end date/time' is intended to record the precise time when the entire testing process was completed. It can be used to document the complex laboratory tests with multiple components such as a Glucose challenge test. Note: the corresponding ACTION time attribute for the 'Test performed' will document the time each component performed was commenced. This 'Final end date/time' data element will record the date/time of the final active component of the test process. This will enable a full duration of the active laboratory test to be calculated, if required. In practice, many test specimens (for example, in ambulatory care) will be collected without a corresponding order (using an INSTRUCTION archetype) once and not be ordered in advance. The details about the laboratory test will be added against the pathway step, 'Specimen collected'. In point of care testing, the specimen may be collected and the test recorded as completed against the 'Test completed' pathway step without an order or recording of data against any other pathway steps. In some cases a recurring laboratory test will be ordered, and in this situation data against the 'Test performed' step will be recorded on each occasion, leaving the instruction in the active state. When the last occurrence is recorded the 'laboratory test completed' action is recorded showing that this order is now in the completed state. In other situations, such as secondary care, there may be a formal order for a laboratory test using a corresponding INSTRUCTION archetype. This ACTION archetype can then be used to record the workflow of when and how the order has been carried out. Recording information using this ACTION archetype indicates that some sort of activity has actually occurred; this will usually be the laboratory test itself but may be a failed attempt or another activity such as postponing the laboratory test. If there is a formal order for the laboratory test, the state of this order is represented by the Pathway step against which the data is recorded. For example, using this archetype the progressing state of a pre-operative blood test order may be recorded through separate entries in the EHR progress notes at each 'Pathway' step: - record the scheduled Start date/time for the test (Test scheduled); and - record that the laboratory test has been completed, including information about the laboratory test details (Test completed). Please note that in the openEHR Reference Model there is a 'Time' attribute, which is intended to record the date and time at which each pathway step of the Action was performed. This is the attribute to use to record the start of the laboratory test (using the 'Test performed' pathway step) or the time that the laboratory test was aborted (using the 'Test aborted' pathway step).
MisuseNot to be used to record details about the test result - use the OBSERVATION.laboratory_test_result archetype for this purpose. Not to be used to record details about administrative activities - use specific ADMIN archetypes for this purpose. Not to be used to record details about related activities such as medication administered as part of the laboratory test or when imaging guidance is used during the laboratory test - use separate and specific ACTION archetypes within the same template for this purpose.
PurposeTo record information about the activities required to carry out a laboratory test, including the planning, scheduling, performance, suspension, cancellation, documentation and completion.
References
Copyright© openEHR Foundation
AuthorsAuthor name: Heather Leslie
Organisation: Atomica Informatics, Australia
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2007-03-12
Other Details LanguageAuthor name: Heather Leslie
Organisation: Atomica Informatics, Australia
Email: heather.leslie@atomicainformatics.com
Date originally authored: 2007-03-12
OtherDetails Language Independent{licence=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/., custodian_organisation=openEHR Foundation, current_contact=Heather Leslie, Atomica Informatics, heather.leslie@atomicainformatics.com, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=B57A070B23A6181E288B899E79EE6F39, build_uid=0bfd9d44-0788-4933-87c3-0bd9631c12fd, revision=0.0.1-alpha}
Keywordslaboratory, test, diagnostic, evaluation, investigation, screening
Lifecyclein_development
UID7ca6804b-966d-469d-b21f-7246ad739fb0
Language useden
Citeable Identifier1013.1.6558
Revision Number0.0.1-alpha
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