| TEMPLATE ID | Generic Laboratory Test Report.v0 |
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| Concept | Generic Laboratory Test Report.v0 |
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| Description | Demonstrates use of laboratory test and component archetypes to align with a typical battery/panel type lab message. |
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| Purpose | Demonstrates use of laboratory test and component archetypes to align with a typical battery/panel type lab message. |
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| References | |
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| Other Details (Language Independent) | - MetaDataSet:Sample Set : Template metadata sample set
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| Language used | en |
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| Citeable Identifier | 1013.26.185 |
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| Root archetype id | openEHR-EHR-COMPOSITION.report-result.v1 |
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| Laboratory test report | Laboratory test report: Document to communicate information to others about the result of a test or assessment. |
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| Laboratory test | Laboratory test: The findings and interpretation of a pathology laboratory test performed on patient-related specimens.
This archetype may be used to record a single valued test, but will often be specialised or templated to represent multiple value or 'panel' tests. This archetype also acts as the parent for specialisations appropriate for more specific laboratory tests, e.g. microbiology, histopathology. |
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| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
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| Data | |
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| Test name | Test name: Identification of the pathology test performed, sometimes including specimen type and patient state.
A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy".
Optional[{fhirmapping=Diagnostic.Reportname, fhirvalueset=reportnames}] |
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| Specimen | Specimen: To record details of a laboratory specimen. |
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| Specimen type | Specimen type: The type of specimen to be collected e.g venous blood, prostatic biopsy.
Optional[{fhir_mapping=Specimen.type}] |
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| Datetime collected | Datetime collected: The date and time that collection has been ordered to take place or has taken place. |
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| Sampling conditions | Sampling conditions: Any conditions to be met before the sample should be taken.
e.g. fasting, 'full bladder', 'sterile field' or any special instructions on the handling or immediate processing of the sample e.g. centrifuge on receipt.
Can also be used to document any known deviations from collection or handling instructions e.g patient was not fasted. |
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| Collection method | Collection method: The method of collection to be used eg Venepuncture, biopsy, resection.
Optional[{fhir_mapping=Specimen.collection.method}] |
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| Collection method description | Collection method description: Additional detailed description of method of sample collection. |
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| Potential risk | Potential risk: Any risk or biohazard associated with collecting or handling the specimen. |
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| Collection setting | Collection setting: Identification of the setting at which the specimen was collected
from a subject of care. The specimen is often collected by a
healthcare provider, but may be collected directly by the patient or carer at home.
This specifies the specimen collection location within the healthcare
environment. It enables the laboratory to ask questions about the
collection of the specimen, if required. The specimen collection
setting may provide additional information relevant to the analysis
of the result. |
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| Specimen collector identifier | Specimen collector identifier: Identifier of the person or agency responsible for collecting the specimen.
Optional[{fhir_mapping=Specimen.collection.collector}] |
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| Number of containers | Number of containers: The total number of containers holding this specimen.
>=0 |
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| Specimen container | Specimen container: Details of a specimen container. This is often integral to workflow and reporting of pathology specimens, particularly anatomical and histological pathology specimens. |
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| Container type | Container type: The type of container.
 Coded Text- Tissue cassette
- Tissue microarray cassette
- Specimen vial
- Microscope slide
- Specimen container
- Electron microscopy grid
- Specimen well
 Text
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| Container additive | Container additive: Any special fixative or transport medium requirements. |
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| Description | Description: A text description of the container. |
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| Datetime transported | Datetime transported: The data and time that the specimen was uplifted for transportation to the laboratory. |
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| Container Identifier | Container Identifier: The unique identifier given to the container. May be multiple. |
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| Collection area Identifier | Collection area Identifier: Identifier of the place from where the container should be collected. |
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| Transporter identifier | Transporter identifier: Identifier of person or agency responsible for transporting the container to the lab. |
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| Specimen quality | Specimen quality: Problems with the received specimen. |
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| Specimen received issues | Specimen received issues: Specific issue with a received specimen.
- Coded Text
- Haemolysed
- Lipaemic
- Incorrect transport medium
- Insufficient sample
- Text
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| Laboratory handling issues | Laboratory handling issues: Issue arising with handling or processing of the specimen within the laboratory.
- Coded Text
- Handling error
- Age
- Laboratory accident
- Technical failure
- Text
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| Adequacy for testing | Adequacy for testing: Is the specimen adequate for testing?
- Coded Text
- Satisfactory
- Unsatisfactory - processed
- Unsatisfactory - not processed
- Text
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| Comment | Comment: An additional text comment on the quality of the received specimen. |
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| Processing | Processing: Workflow of specimen processing/handling. |
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| Datetime received | Datetime received: The date and time that the sample was received at the laboratory.
Optional[{fhir_mapping=Specimen.receivedTime}] |
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| Laboratory specimen identifier | Laboratory specimen identifier: Unique identifier of the specimen, normally assigned by the laboratory.
Sometimes called the Accession Identifier.
Optional[{fhir_mapping=Specimen.accessionIdentifier}] |
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| Related specimen | Related specimen: Details of a related specimen. |
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| Parent specimen identifier | Parent specimen identifier: Unique identifier of the parent specimen, where the specimen is split into sub-samples. |
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| Test status | Test status: The status of the laboratory test result as a whole.
Optional[{fhir_mapping=DiagnosticReport.status}]
- Registered
- Partial
- Final
- Corrected
- Amended
- Cancelled
- Entered in error
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| Test status timestamp | Test status timestamp: The date and/or time that the entire result was issued for the recorded ‘Test Report Status’.
Optional[{fhir_mapping=DiagnosticReport.issued}] |
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| Diagnostic service category | Diagnostic service category: The diagnostic service that performs the examination.
For example, biochemistry, haematology. This helps clinicians filter for broad categories of results accoridng to local laboratory arrangements. Coding with a terminology is desirable, where possible.
Optional[{fhir_mapping=DiagnosticReport.serviceCategory, fhir_valueset=diagnostic-service-sections}] |
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| Clinical information provided | Clinical information provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request.
In HL7 fhir this information is held within the linked requestDetail.clinical Notes.
Optional[{fhir_mapping=DiagnosticReport.requestDetail.clinicalNotes}] |
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| Laboratory test panel | Laboratory test panel: Laboratory test result as a single value or in a panel/battery format common to clinical pathology testing. |
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| Laboratory result | Laboratory result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. |
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| Result value | Result value: Actual value of the result. The name of this element is normally replaced in a template or at run-time to relfect the actual analyte e.g. Serum sodium and will often be coded.
Optional[{fhir_mapping=Observation.result; Observation.name, hl7v2_mapping=OBX.2,OBX.5,OBX.6; OBX-3-observation identifier}] |
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| Comment | Comment: Comment about the Result.
Optional[{fhir_mapping=Observation.comments, hl7v2_mapping=NTE.3}] |
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| Reference range guidance | Reference range guidance: Additional advice on the applicability of the reference range. |
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| Result status | Result status: The status of the result value.
Optional[{fhir_mapping=status, hl7v2_mapping=OBX-11-observation result status}]
- Registered
- Interim
- Final
- Amended
- Cancelled/Aborted
- Not requested
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| Result status timestamp | Result status timestamp: The date and/or time that the entire result was issued for the recorded ‘Result status’.
Optional[{fhir_mapping=Observation.issued, hl7v2_mapping=OBX-22 and/or OBX-19}] |
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| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the laboratory test results.
Optional[{fhir_mapping=DiagnosticReport.conclusion}] |
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| Pathological diagnosis | Pathological diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'.
Coding with a terminology is preferred, where possible.
Optional[{fhir_mapping=DiagnosticReport.codedDiagnosis}] |
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| Comment | Comment: Additional narrative about the test not captured in other fields. |
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| Test representation | Test representation: Rich text or other multimedia representation of the entire result as issued by the diagnostic service.
Multiple formats are allowed but they must be semantically equivalent.
Optional[{fhir_mapping=DiagnosticReport.presentedForm}] |
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| Confounding factors | Confounding factors: Aspects of the condition or circumstances of the patient that may alter interpretation of the laboratory test. |
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| Laboratory test identifier | Laboratory test identifier: The local identifier given to the laboratory test result by the Laboratory Information System.
Optional[{fhir_mapping=DiagnosticReport.identifier}] |
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| Test request details | Test request details: Details concerning a single laboratory test requested.
Usually there is one test request (or "order") for each result, however in some circumstances multiple test requests may be represented using a single Pathology test result archetype.
Optional[{fhir_mapping=DiagnosticReport.requestDetail}] |
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| Original test requested Name | Original test requested Name: Identification of the original laboratory test requested, where the test requested differs from the test actually performed. |
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| Requester order identifier | Requester order identifier: The local ID assigned to the test order by the order requester.
Equivalent to the HL7 Placer Order Identifier. |
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| Receiver order identifier | Receiver order identifier: The local ID 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. |
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| Point of care device | Point of care device: True if a point of care device supplies the test result rather than a formal laboratory service.
Assumed value: false |
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