| TEMPLATE ID | Laboratory test screening - JM |
|---|---|
| Concept | Laboratory test screening - JM |
| Description | Not Specified |
| Purpose | Not Specified |
| References | |
| Authors | name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2024-12-29 |
| Other Details Language | name: Heather Leslie; organisation: Atomica Informatics; email: heather.leslie@atomicainformatics.com; date: 2024-12-29 |
| Other Details (Language Independent) |
|
| Language used | en |
| Citeable Identifier | 1013.26.1114 |
| Root archetype id | openEHR-EHR-OBSERVATION.investigation_screening.v1 |
| Laboratory test screening | Laboratory test screening: Series of questions and associated answers used to screen whether diagnostic investigations have been carried out. The answers may be self-reported. |
| Data | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Data | |
| Specimen taken? | Specimen taken?: Is there a history of any diagnostic tests or investigations related to the screening purpose? In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
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| Specific test | Specific test: Details about a specified investigation or grouping of investigations relevant for the screening purpose. Use separate instances of this CLUSTER to differentiate between specific investigations or groupings of investigations. |
| Test name | Test name: Name of the diagnostic investigation or grouping of investigations. For example: 'Blood gas', Chest Xray', 'ECG'; or 'Hearing test'. Coding of the 'Investigation name' with a terminology is preferred, where possible. |
| Done? | Done?: Is there a history of the investigation being carried out? In a template, the data element would usually be renamed to the specific question asked. The proposed value set can be adapted for local use by using the DV_TEXT or the DV_BOOLEAN datatypes choice to match each specific use case.
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| Type | Type: The method, technique, modality or other more specific identification of the diagnostic investigation. For example: contrast-enhanced mammography, magnification mammography, mammographic digital tomosynthesis, contrast imaging technique, fluorescence in situ hybridisation, Immunoassay method. |
| Date/time result reported | Date/time result reported: Indication of timing related to the investigation. The 'Timing' data element has deliberately been loosely modelled to support the myriad of ways that it can be used in questionnaires to capture when an investigation was carried out. The specific and intended semantics can be further clarified in a template. For example: the actual date and/or time; the start and stop time for the investigation; the interval of time during which the investigation was carried out; the duration of the investigation; the age of the individual at the time of the investigation; or the duration of time since it occurred. A partial date is valid, using the DV_DATE_TIME data type, to record only a year. |
| Conclusion | Conclusion: Brief description, summary or interpretation of the investigation outcome. For example: 'All results within normal range', 'Normal', 'Further investigations needed'. This data element is not to contain a representation of the actual results or findings of laboratory tests. In that situation, nest a CLUSTER archetype carrying the structured result within the following 'Additional details' SLOT, for example the CLUSTER.laboratory_test_analyte archetype. |
| Specimen collection details | Specimen collection details: 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 type | Specimen 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}] Annotations
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| Date/time received by laboratory | Date/time received by laboratory: The date and time that the sample was received at the laboratory. Optional[{fhir_mapping=Specimen.receivedTime}] Annotations
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| Date/time collected | Date/time collected: 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. |
| Adequacy for testing | Adequacy 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.
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| Comment | Comment: Additional narrative about the specimen not captured in other fields. Optional[{fhir_mapping=Specimen.note}] Annotations
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| Comment | Comment: Additional narrative about the diagnostic investigation test not captured in other fields. |