ARCHETYPE ID | openEHR-EHR-INSTRUCTION.service_request-laboratory_test.v0 |
Concept | Laboratory test request |
Description | An order or instruction for a laboratory test service. |
Use | Use to record a request for a laboratory test service. The archetype has been designed to represent a request for one or more laboratory test services, in one of two ways: - If multiple services need to be requested but the information recorded in the 'protocol' (for example 'Receiver') is the same - use a separate 'Activity' instance within this archetype for each request. The user interface in the clinical system may be able to support duplication of request details such as 'Fasting status', 'Clinical Indication', 'Reason for request', and 'Service due') where these are identical for each activity. - If multiple services need to be requested and the information recorded in the 'protocol' (for example 'Receiver') is different - use a separate instance of this archetype for each request. The 'Service due' data element supports common use cases for stipulating the simple timing for delivery of the request/s on a single occasion. For situations with more complicated timing requirements or a series of services, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT. Implementation examples: - Consider a clinician managing an elderly patient with Type 2 Diabetes ordering 'HbA1c' and a fasting 'Glucose' - the 'Service name' will carry both 'Haemoglobin A1C' and 'Glucose'; the 'Clinical indication' may be 'Type 2 Diabetes'; the 'Reason for request' may be 'Monitor glucose control' and 'Fasting status' will be 'Fasting'. - Consider a clinician managing a patient with chest pain - the 'Service name' will carry 'Urea', 'Electrolytes', 'Creatinine', 'GFR estimated (eGFR)', 'Glucose', 'Liver function tests', 'Troponin I', 'Troponin T', and 'Full blood count'; 'Clinical indication' will be 'Chest pain'; the 'Reason for request may be 'Exclude AMI'; and the 'Clinical context' may be '4 hours of atypical left-sided chest pain and associated nausea'. - Consider a clinician ordering a recurring blood test, such as an INR. The complex timing for this requires the use of the CLUSTER.service_direction and associated CLUSTER.timing_nondaily archetype nested within the 'Complex timing' SLOT to clearly define the frequency and timing for each sequence in a series of tests, such as 'daily for one week, weekly for 4 weeks, monthly for 6 months'. In many situations, it will be possible to record the steps that occur as part of this request being carried out using the corresponding generic ACTION.service. However, there will be many occasions where the required ACTION archetype will be very specific for purpose, as the data requirements for recording provision of many health-related services will need quite unique data elements, recording patterns or pathway steps. For example: ACTION.screening or ACTION.health_education. |
Misuse | Not to be used to record details about the activities that document how an order or request has been carried out - use an ACTION archetype for this purpose. For example ACTION.service archetype or a more purpose-specific archetype from the ACTION class for this purpose. Not to be used to record a Laboratory test result - use the OBSERVATION.laboratory_test_result for this purpose. |
Purpose | To record a request for a laboratory test service. |
References | Anecdotal evidence provided by existing laboratory test request forms. |
Copyright | © openEHR Foundation, Nasjonal IKT HF |
Authors | Author name: Dr Heather Leslie Organisation: Atomica Informatics, Australia Email: heather.leslie@atomicainformatics.com Date originally authored: 2024-04-04 |
Other Details Language | Author name: Dr Heather Leslie Organisation: Atomica Informatics, Australia Email: heather.leslie@atomicainformatics.com Date originally authored: 2024-04-04 |
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, references=Anecdotal evidence provided by existing laboratory test request forms., current_contact=Heather Leslie, Atomica Informatics |
Keywords | request, order, service, provide, referral |
Lifecycle | in_development |
UID | 9d0f49c7-f910-41cc-9627-640f152566ed |
Language used | en |
Citeable Identifier | 1013.1.7230 |
Revision Number | 0.0.1-alpha |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=An order or instruction for a laboratory test service., archetypeConceptComment=null, otherContributors=Fatima Almeida, Critical SW, Portugal Tomas Alme, DIPS ASA, Norway Vebjørn Arntzen, Oslo University Hospital, Norway Koray Atalag, University of Auckland, New Zealand Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) Lars Bitsch-Larsen, Haukeland University hospital, Norway Anita Bjørnnes, Helse Bergen, Norway Lisbeth Dahlhaug, Helse Midt - Norge IT, Norway Einar Fosse, UNN HF, Norwegian Centre for Integrated Care and Telemedicine, Norway Hildegard Franke, freshEHR Clinical Informatics Ltd., United Kingdom Heather Grain, Llewelyn Grain Informatics, Australia Knut Harboe, Stavanger Universitetssjukehus, Norway Sam Heard, Ocean Informatics, Australia Ingrid Heitmann, Oslo universitetssykehus HF, Norway Andreas Hering, Helse Bergen HF, Haukeland universitetssjukehus, Norway Anca Heyd, DIPS ASA, Norway Hilde Hollås, DIPS AS, Norway Evelyn Hovenga, EJSH Consulting, Australia Lars Ivar Mehlum, Helse Bergen HF, Norway Lars Morgan Karlsen, DIPS ASA, Norway Shinji Kobayashi, Kyoto University, Japan Heather Leslie, Atomica Informatics, Australia (openEHR Editor) Hallvard Lærum, Direktoratet for e-helse, Norway Rose Mari Eikås, Helse Bergen, Norway Ole Martin Sand, DIPS ASA, Norway Hildegard McNicoll, freshEHR Clinical Informatics Ltd., United Kingdom Ian McNicoll, freshEHR Clinical Informatics, United Kingdom (openEHR Editor) Bjørn Næss, DIPS ASA, Norway Andrej Orel, Marand d.o.o., Slovenia Anne Pauline Anderssen, Helse Nord RHF, Norway Pablo Pazos, CaboLabs.com Health Informatics, Uruguay Rune Pedersen, Universitetssykehuset i Nord Norge, Norway Jussara Rotzsch, Hospital Alemão Oswaldo Cruz, Brazil Line Silsand, Universitetssykehuset i Nord-Norge, Norway Norwegian Review Summary, Nasjonal IKT HF, Norway Line Sæle, Nasjonal IKT HF, Norway Nyree Taylor, Ocean Informatics, Australia John Tore Valand, Haukeland Universitetssjukehus, Norway (Nasjonal IKT redaktør) Richard Townley-O'Neill, Australian Digital Health Agency, Australia Gro-Hilde Ulriksen, Norwegian center for ehealthresearch, Norway, originalLanguage=en, translators=
openEHR-EHR-CLUSTER.person.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0011], code=at0011, itemType=ELEMENT, level=2, text=Receiver order identifier, description=The local identifier assigned to the request by the clinician or organisation receiving the request for service., comment=Usually equivalent to the HL7 Filler Order Identifier., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
openEHR-EHR-CLUSTER.person.v1 and specialisations or openEHR-EHR-CLUSTER.organisation.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0127], code=at0127, itemType=ELEMENT, level=2, text=Request status, description=The status of the request for service as indicated by the requester., comment=Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. Coding with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0128], code=at0128, itemType=SLOT, level=2, text=Distribution list, description=Details of additional clinicians, organisations or agencies who require copies of any communication., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.organisation.v1 and specialisations or openEHR-EHR-CLUSTER.person.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0155], code=at0155, itemType=SLOT, level=2, text=Urgent contact, description=Details about the designated contact person or organisation and preferred mode of contact for urgent or emergency notifications related to this request., comment=For example: if the outcome of the request requires an urgent or emergency response by the requester., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.person.v1 and specialisations or openEHR-EHR-CLUSTER.organisation.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0158], code=at0158, itemType=ELEMENT, level=2, text=Eligibility guidance, description=Advice from the requester to the receiver about the individual's eligibility for the requested service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0156], code=at0156, itemType=ELEMENT, level=2, text=Billing guidance, description=A recommendation from the requester to the receiver about the method of payment for the service., comment=For example: 'Private'; 'Government insurance scheme'; or 'Private insurance'. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0157], code=at0157, itemType=SLOT, level=2, text=Responsible payer, description=Details about the individual or organisation who will assume responsibility for payment of the service., comment=This data element will only be used if a known payer has been identified. For example: an individual, such as a parent on behalf of a child; or an organisation such as a workplace or government insurance scheme., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.organisation.v1 and specialisations or openEHR-EHR-CLUSTER.person.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0112], code=at0112, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: All not explicitly excluded archetypes, extendedValues=null]], ism_transition=[], context=[], data=[], activities=[ResourceSimplifiedHierarchyItem [path=/activities[at0001], code=at0001, itemType=ACTIVITY, level=1, text=Current Activity, description=Current Activity., comment=null, uncommonOntologyItems=null, occurencesFormal=1..*, occurencesText=Mandatory, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=null, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0009]/items[at0121], code=at0121, itemType=ELEMENT, level=2, text=Service name, description=The name of the service/s requested., comment=Coding of the 'Service name' with an external terminology is strongly recommended, if available. This data element allows multiple occurrences to enable the user to record a multiple services as part of a single request, if required., 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=/activities[at0001]/description[at0009]/items[at0.1], code=at0.1, itemType=ELEMENT, level=2, text=Fasting status, description=Request requirement for the patient to be fasted at the time of specimen collection., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
openEHR-EHR-CLUSTER.service_ openEHR-EHR-CLUSTER.timing_ openEHR-EHR-CLUSTER.timing_ openEHR-EHR-CLUSTER.specimen.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0009]/items[at0.5], code=at0.5, itemType=SLOT, level=2, text=Collected specimen, description=Details about a specimen that has been collected either by the requester or self-collected by the patient, and submitted for analysis as part of this laboratory request., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.specimen.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0009]/items[at0132], code=at0132, itemType=SLOT, level=2, text=Specific details, description=Additional detail about the service requested., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0009]/items[at0149], code=at0149, itemType=SLOT, level=2, text=Supporting information, description=Digital document, image, video or diagram supplied as additional information to support or inform the request., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.media_ All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/activities[at0001]/description[at0009]/items[at0150], code=at0150, itemType=ELEMENT, level=2, text=Comment, description=Additional narrative about the service request not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null]], relationships=[], credentials=[], target=[], source=[], state=[], content=[], contacts=[], capabilities=[]}, topLevelItems={protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0008], code=at0008, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=1..*, subCardinalityText= , dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], activities=ResourceSimplifiedHierarchyItem [path=ROOT_/activities[at0001], code=at0001, itemType=ACTIVITY, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=null, occurencesText=null, cardinalityFormal=0..*, cardinalityText=Minimum of 0 items , subCardinalityFormal=null, subCardinalityText=null, dataType=ACTIVITY, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0010], code=at0010, itemType=ELEMENT, level=2, text=Requester order identifier, description=The local identifier assigned by the requesting clinical system., comment=Usually equivalent to the HL7 Placer Order Identifier., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
openEHR-EHR-CLUSTER.person.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0011], code=at0011, itemType=ELEMENT, level=2, text=Receiver order identifier, description=The local identifier assigned to the request by the clinician or organisation receiving the request for service., comment=Usually equivalent to the HL7 Filler Order Identifier., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
openEHR-EHR-CLUSTER.person.v1 and specialisations or openEHR-EHR-CLUSTER.organisation.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0127], code=at0127, itemType=ELEMENT, level=2, text=Request status, description=The status of the request for service as indicated by the requester., comment=Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. Coding with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0128], code=at0128, itemType=SLOT, level=2, text=Distribution list, description=Details of additional clinicians, organisations or agencies who require copies of any communication., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.organisation.v1 and specialisations or openEHR-EHR-CLUSTER.person.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0155], code=at0155, itemType=SLOT, level=2, text=Urgent contact, description=Details about the designated contact person or organisation and preferred mode of contact for urgent or emergency notifications related to this request., comment=For example: if the outcome of the request requires an urgent or emergency response by the requester., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.person.v1 and specialisations or openEHR-EHR-CLUSTER.organisation.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0158], code=at0158, itemType=ELEMENT, level=2, text=Eligibility guidance, description=Advice from the requester to the receiver about the individual's eligibility for the requested service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0156], code=at0156, itemType=ELEMENT, level=2, text=Billing guidance, description=A recommendation from the requester to the receiver about the method of payment for the service., comment=For example: 'Private'; 'Government insurance scheme'; or 'Private insurance'. , uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0157], code=at0157, itemType=SLOT, level=2, text=Responsible payer, description=Details about the individual or organisation who will assume responsibility for payment of the service., comment=This data element will only be used if a known payer has been identified. For example: an individual, such as a parent on behalf of a child; or an organisation such as a workplace or government insurance scheme., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.organisation.v1 and specialisations or openEHR-EHR-CLUSTER.person.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0008]/items[at0112], code=at0112, itemType=SLOT, level=2, text=Extension, description=Additional information required to extend the model with local content or to align with other reference models or formalisms., comment=For example: local information requirements; or additional metadata to align with FHIR., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |