TEMPLATE COVID-19 Pneumonia Diagnosis and Treatment (7th edition) (COVID-19 Pneumonia Diagnosis and Treatment (7th edition))

TEMPLATE ID	COVID-19 Pneumonia Diagnosis and Treatment (7th edition)
Concept	COVID-19 Pneumonia Diagnosis and Treatment (7th edition)
Description	The template is developed to promote interoperability among systems for the diagnosis and treatment of COVID-19. The data points included in the template were abstracted from the 7th version of Diagnosis and Treatment Guideline of COVID-19 released by the National Health Commission of the People's Republic of China (Printed and distributed on March 3, 2020), the translated English version can be found in https://www.chinalawtranslate.com/en/coronavirus-treatment-plan-7/.
Use	To exchange data required for decision support of diagnosis and treatment of COVID-19, such as for being used in the production rules in CDSS.
Misuse	There may be some differences in the guidelines issued by authorities from other countries. Therefore, the specific requirements and clinical environment of the country or region should be examined.
Purpose	The template is developed to promote interoperability among systems for the diagnosis and treatment of COVID-19. The data points included in the template were abstracted from the 7th version of Diagnosis and Treatment Guideline of COVID-19 released by the National Health Commission of the People's Republic of China (Printed and distributed on March 3, 2020), the translated English version can be found in https://www.chinalawtranslate.com/en/coronavirus-treatment-plan-7/.
References
Authors	name: Xudong Lu; organisation: Zhejiang University; email: lvxd@zju.edu.cn; date: 2020-04-07
Other Details Language	name: Xudong Lu; organisation: Zhejiang University; email: lvxd@zju.edu.cn; date: 2020-04-07
Other Details (Language Independent)	MetaDataSet:Sample Set: Template metadata sample set MD5-CAM-1.0.1: 1a36be5935c97561ec3b9a57fb7289d5 PARENT:MD5-CAM-1.0.1: 706E6DA39FA082EE75E0F0D4E4A87F25
Keywords	openEHR; COVID-19; Diagnosis; Treatment; CDS
Language used	en
Citeable Identifier	1013.26.291
Revision	4
Root archetype id	openEHR-EHR-COMPOSITION.encounter.v1
COVID-19 Pneumonia Diagnosis and Treatment (7th edition)	COVID-19 Pneumonia Diagnosis and Treatment (7th edition): Interaction, contact or care event between a subject of care and healthcare provider(s).
Clinical background	Clinical background: A generic section header which should be renamed in a template to suit a specific clinical context.
Age	Age: Details about the age of an individual.
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
Chronological age	Chronological age: Age based on actual date of birth.
Adjusted age	Adjusted age: Age based on due date.
Symptom/sign screening questionnaire	Symptom/sign screening questionnaire: An individual- or self-reported questionnaire screening for symptoms and signs.
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
Screening purpose	Screening purpose: The reason for overall screening. For example: screening for an infectious disease, such as SARS-COV-2. Terminology: S Suspected disease caused by SARS-CoV-2
Symptomatic/Asymptomatic?	Symptomatic/Asymptomatic?: Presence of any relevant symptoms or signs. Present Absent Unknown
Typical symptom/sign	Typical symptom/sign: Grouping of data elements related to screening for a single symptom or sign.
Symptom or sign name	Symptom or sign name: Name of the symptom or sign being screened. Terminology: SNOMED-CT Fever Fatigue Dry cough Nasal congestion Nasal discharge Sore throat Muscle pain Shortness of breath Diarrhea
Presence?	Presence?: Presence of the symptom or sign. Present Absent Unknown
Child specific symptom/sign	Child specific symptom/sign: Grouping of data elements related to screening for a single symptom or sign.
Symptom or sign name	Symptom or sign name: Name of the symptom or sign being screened. Terminology: SNOMED-CT Vomiting Drowsiness Lethargy Convulsion Infant feeding problem Dehydration Distressed breathing Crying
Presence?	Presence?: Presence of the symptom or sign. Present Absent Unknown
Condition/finding screening questionnaire	Condition/finding screening questionnaire: An individual- or self-reported questionnaire screening for conditions, including problems, diagnoses and pregnancy.
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
Specific condition	Specific condition: Grouping of data elements related to screening for a single condition.
Condition name	Condition name: Name of the condition being screened. Terminology: SNOMED-CT Hypoxemia Cyanosis Acute respiratory distress syndrome Septic shock Metabolic acidosis Blood coagulation disorder Shock Multiple organ failure Pregnant Comorbid conditions Immunodeficiency Acute respiratory failure
Presence?	Presence?: Presence of the condition. Present Absent Unknown
Pregnancy gestation	Pregnancy gestation: The date/time when any conditions were first noticed. Partial dates are allowed. Duration Coded Text First trimester Second trimester Third trimester
Management/treatment screening questionnaire	Management/treatment screening questionnaire: An individual- or self-reported questionnaire screening for management or treatment carried out.
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
Specific management/treatment activity	Specific management/treatment activity: Grouping of data elements related to screening for a single management or treatment activity.
Activity name	Activity name: Name of the management or treatment activity being screened. Terminology: SNOMED-CT Mechanical ventilation Admission to intensive care unit
Carried out?	Carried out?: Did the management or treatment activity take place? Actioned Not actioned Unknown
Vital signs	Vital signs: A generic section header which should be renamed in a template to suit a specific clinical context.
Body temperature	Body temperature: A measurement of the body temperature, which is a surrogate for the core body temperature of the individual.
Data
Any point in time event	Any point in time event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Temperature	Temperature: The measured temperature. 0..100; 30..200 Units: °C (UCUM: Cel) °F (UCUM: [degF])
Respiration	Respiration: The characteristics of spontaneous breathing by an individual.
Data
Any point in time event	Any point in time event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Rate	Rate: The frequency of spontaneous breathing. 0..200 /min
Pulse oximetry	Pulse oximetry: Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry.
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
SpO₂	SpO₂: The saturation of oxygen in the peripheral blood, measured via pulse oximetry. SpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood. Percent
Laboratory tests	Laboratory tests: A generic section header which should be renamed in a template to suit a specific clinical context.
SARS coronavirus 2 RNA	SARS coronavirus 2 RNA: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC SARS coronavirus 2 RNA
Specimen	Specimen: 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}] Nasopharyngeal secretions Sputum Lower respiratory tract secretions
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC SARS coronavirus 2 RNA
Analyte result	Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Terminology: SNOMED-CT Positive Presumptive positive Negative
Protocol
Test method	Test method: Description about the method used to perform the test. Coding with a terminology is desirable, where possible. RT-PCR Next Generation Sequencing
Serology	Serology: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC SARS coronavirus 2 Ab.IgG & IgM panel
Specimen	Specimen: 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}] Serum or plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC SARS coronavirus 2 Ab.IgG SARS coronavirus 2 Ab.IgM
Analyte result	Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Units: mg/dl g/L
Complete blood count & differential	Complete blood count & differential: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC CBC W Auto Differential panel
Specimen	Specimen: 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}] Blood
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: SNOMED-CT Leukocytes Erythrocytes Hemoglobin Hematocrit Erythrocyte mean corpuscular volume Erythrocyte mean corpuscular hemoglobin Erythrocyte mean corpuscular hemoglobin concentration Platelets Lymphocytes Neutrophils Monocytes Eosinophils Basophils
Arterial blood gases	Arterial blood gases: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Gas panel - Arterial blood
Specimen	Specimen: A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis. For example: Tissue or body fluid.
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC pH pCO2 pO2 HCO3 Base excess
State
Inspired oxygen	Inspired oxygen: The amount of oxygen being delivered, or to be delivered, to the patient given as a fraction, percentage or indirectly as a flow rate.
FiO₂	FiO₂: Fraction of oxygen in inspired air. For example: '0.28'. Unitary
C reactive protein	C reactive protein: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC C reactive protein
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC C reactive protein
Analyte result	Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Units: mg/L
Interleukin 6	Interleukin 6: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Interleukin 6
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Interleukin 6
Liver function panel	Liver function panel: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Liver function panel
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Protein [Mass/volume] in Serum or Plasma Albumin [Mass/volume] in Serum or Plasma Bilirubin.total [Mass/volume] in Serum or Plasma Bilirubin.direct [Mass/volume] in Serum or Plasma Alkaline phosphatase [Enzymatic activity/volume] in Serum or Plasma Aspartate aminotransferase [Enzymatic activity/volume] in Serum or Plasma Alanine aminotransferase [Enzymatic activity/volume] in Serum or Plasma
Creatine kinase	Creatine kinase: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Creatine kinase
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Creatine kinase
Analyte result	Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Units: [iU]/L
Troponins	Troponins: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Troponin T.cardiac [Mass/volume] in Serum or Plasma
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Troponin T.cardiac [Mass/volume] in Serum or Plasma
Analyte result	Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}]
Myoglobin	Myoglobin: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Myoglobin [Mass/volume] in Serum or Plasma
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Myoglobin [Mass/volume] in Serum or Plasma
Analyte result	Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}]
ESR	ESR: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Erythrocyte sedemination rate
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Erythrocyte sedemination rate
Fibrin D-dimer	Fibrin D-dimer: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Fibrin D-dimer
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Fibrin D-dimer
Lactate	Lactate: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Lactate [Moles/volume] in Serum or Plasma
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Lactate [Moles/volume] in Serum or Plasma
Analyte result	Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Units: [iU]/L mmol/L
Comment	Comment: Additional narrative about the test result not captured in other fields.
Lactate dehydrogenase	Lactate dehydrogenase: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Lactate dehydrogenase [Enzymatic activity/volume] in Serum or Plasma
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Lactate dehydrogenase [Enzymatic activity/volume] in Serum or Plasma
Analyte result	Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Units: [iU]/L
Procalcitonin	Procalcitonin: The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
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
Test name	Test name: Name of the laboratory investigation performed on the specimen(s). A test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'. Terminology: LOINC Procalcitonin
Specimen	Specimen: 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}] Serum/plasma
Collection date/time	Collection date/time: 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. Date/Time Interval of Date/Time
Laboratory analyte result	Laboratory analyte result: The result of a laboratory test for a single analyte value.
Analyte name	Analyte name: The name of the analyte result. The value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Terminology: LOINC Procalcitonin
Analyte result	Analyte result: The value of the analyte result. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Units: [iU]/L
PaO2/FiO2 ratio	PaO2/FiO2 ratio: Ratio between the partial pressure of oxygen in blood (PaO2) and the fraction of oxygen in the inhaled air (FiO2). Also known as the PF ration, Carrico index or Horowitz quotient.
Data
Any point in time event	Any point in time event: Default, unspecified point in time event which may be explicitly defined in a template or at run-time.
Data
PaO2/FiO2 ratio	PaO2/FiO2 ratio: Calculated ration value. Ratio
Imaging tests	Imaging tests: A generic section header which should be renamed in a template to suit a specific clinical context.
Chest x-ray	Chest x-ray: Record the findings and interpretation of an imaging examination performed.
Data
Baseline	Baseline: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: The name of the imaging examination or procedure performed. Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex. Terminology: SNOMED-CT Plain chest x-ray
Imaging finding	Imaging finding: A single finding in an imaging examination.
Finding name	Finding name: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Pleural effusion Consolidation Patchy shadows Interstitial changes Infiltration
Presence?	Presence?: The presence or absence of the finding. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Present Absent Indeterminate
Imaging diagnosis	Imaging diagnosis: Single word, phrase or brief description representing the likely condition or diagnosis. This data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result. No obvious signs of pneumonia Presenting with pneumonia
Follow up	Follow up: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: The name of the imaging examination or procedure performed. Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex. Terminology: SNOMED-CT Plain chest x-ray
Imaging finding	Imaging finding: A single finding in an imaging examination.
Finding name	Finding name: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Pleural effusion Consolidation Patchy shadows Interstitial changes Infiltration
Presence?	Presence?: The presence or absence of the finding. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Present Absent Indeterminate
Comparison to previous	Comparison to previous: Narrative description about the difference between a previous finding and the finding in this report. Improving Unchanged Worsening
Imaging diagnosis	Imaging diagnosis: Single word, phrase or brief description representing the likely condition or diagnosis. This data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result. No obvious signs of pneumonia Presenting with pneumonia
CT Chest	CT Chest: Record the findings and interpretation of an imaging examination performed.
Data
Baseline	Baseline: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: The name of the imaging examination or procedure performed. Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex. Terminology: SNOMED-CT Computed tomography of chest
Imaging finding	Imaging finding: A single finding in an imaging examination.
Finding name	Finding name: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Pleural effusion Consolidation Patchy shadows Interstitial changes Infiltration Ground glass opacities
Presence?	Presence?: The presence or absence of the finding. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Present Absent Indeterminate
Imaging diagnosis	Imaging diagnosis: Single word, phrase or brief description representing the likely condition or diagnosis. This data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result. No obvious signs of pneumonia Presenting with pneumonia
Follow up	Follow up: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Test name	Test name: The name of the imaging examination or procedure performed. Coding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex. Terminology: SNOMED-CT Computed tomography of chest
Imaging finding	Imaging finding: A single finding in an imaging examination.
Finding name	Finding name: The name of the finding. Coding with an external terminology is strongly recommended. Optional[{fhir_mapping=Observation.code, hl7v2_mapping=OBX.3}] Pleural effusion Consolidation Patchy shadows Interstitial changes Infiltration Ground glass opacities
Presence?	Presence?: The presence or absence of the finding. For example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details. Optional[{fhir_mapping=Observation.value[x], hl7v2_mapping=OBX.2, OBX.5, OBX.6, OBX.7, OBX.8}] Present Absent Indeterminate
Comparison to previous	Comparison to previous: Narrative description about the difference between a previous finding and the finding in this report. Improving Unchanged Worsening
Imaging diagnosis	Imaging diagnosis: Single word, phrase or brief description representing the likely condition or diagnosis. This data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result. No obvious signs of pneumonia Presenting with pneumonia
Assessment	Assessment: A generic section header which should be renamed in a template to suit a specific clinical context.
COVID-19 exposure assessment	COVID-19 exposure assessment: Details about actual or potential exposure to a chemical, physical or biological agent which has caused or may cause harm to an individual.
Data
Last 14 days	Last 14 days: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Exposure	Exposure: The name of the chemical, physical or biological agent to which an individual may have been exposed. Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: 2019-nCoV; or HIV. Terminology: SNOMED-CT Exposure to severe acute respiratory syndrome coronavirus 2
Per risk factor	Per risk factor: Details about each possible exposure risk factor.
Risk factor	Risk factor: The name of the exposure risk factor. For example: Travel to an 'at risk' location; or exposure to infected body fluids. Coding of 'Risk factor' with a terminology is preferred, where possible. Travel to an at risk location Reside in an at risk location Contact with an infected person Contact with an at risk person
Presence	Presence: Presence of the exposure risk factor. Present Indeterminate Absent
COVID-19 clinical assessment	COVID-19 clinical assessment: Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.
Data
Health risk	Health risk: Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name. Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia. Terminology: SNOMED-CT Disease caused by severe acute respiratory syndrome coronavirus 2
Clinical manifestation	Clinical manifestation: Details about each possible risk factor.
Clinical factor	Clinical factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Presentation with fever and/or respiratory symptoms Imaging consistent with COVID-19 pneumonia Early levels of leukocytes or lymphocytes normal or decreased RT-PCR positive for COVID-19 Gene sequencing highly homologous with COVID-19 IgM and IGM positive for COVID-19
Presence	Presence: Presence of the risk factor. Present Indeterminate Absent
Protocol
Last updated	Last updated: The date this health risk assessment was last updated. This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician.
Risk of severe and critical disease	Risk of severe and critical disease: Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.
Data
Health risk	Health risk: Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name. Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia. Risk of severe or critical disease
Adult risk factors	Adult risk factors: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Progressive decrease in lympocytes. Progressive increase in inflammatory biomarkers, including IL-6 and CRP. Progressive increase in lactic acid. Rapid progression of lung lesions.
Presence	Presence: Presence of the risk factor. Present Indeterminate Absent
Child risk factors	Child risk factors: Details about each possible risk factor.
Risk factor	Risk factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Increase in respiratory rate Poor mental reaction and drowsiness. Progressive increase in lactic acid. Infiltration on both sides or in multiple lobes on chest x-ray. Pleural effusion on chest x-ray. Rapid progression of lung lesions on chest x-ray. Underlying diseases (for example congenital heart disease, bronchopulmonary dysplasia, respiratory tract deformity, abnormal hemoglobin and sever malnutrition etc) Underlying immunodeficiency.
Presence	Presence: Presence of the risk factor. Present Indeterminate Absent
Differential diagnoses	Differential diagnoses: A list of one or more possible conditions or diagnoses that may be responsible for the clinical presentation, examination findings and test results.
Data
Differential diagnosis	Differential diagnosis: Details about a single differential diagnosis.
Diagnosis	Diagnosis: Name of the differential diagnosis. Upper respiratory tract infections COVID-19 pneumonia Other viral pneumonia Mycoplasma pneumonia Vasculitis Dermatomyositis Cryptogenic organising pneumonia
Likelihood	Likelihood: Likelihood of this diagnosis being present. Coded Text Suspected Likely Text
Treatment	Treatment: A generic section header which should be renamed in a template to suit a specific clinical context.
Treatment	Treatment: An order or instruction for a health-related therapy or activity to be carried out.
Current Activity	Current Activity: Current Activity.
Description
Activity name	Activity name: The name of the single therapy or activity requested. Coding of the 'Activity name' with a coding system is desirable, if available. For example: 'recommendation to rest in bed'; 'apply ice for 20 minutes every 2 hours'. Terminology: SNOMED-CT Isolation because of infection Bedrest Admission to intensive care unit Fluid balance monitoring Feeding and dietry regime Vital signs monitoring Oxygen therapy support Antiviral therapy Antibiotic therapy Extracorporeal membrane oxygenation Non-invasive ventilation Mechanical ventilation Prone body position Circulatory care Renal care Immunotherapy Termination of pregnancy Traditional Chinese Medicine therapy Psychological counselling
Medication recommendation	Medication recommendation: An order for a medication, vaccine, nutritional product or other therapeutic item for an identified individual.
Order	Order: Details of the requested order.
Description
Medication item	Medication item: Name of the medication, vaccine or other therapeutic/prescribable item being ordered. Depending on the prescribing context this field could be used for either generic- or product-based prescribing. This data field can be used to record tightly bound orders of different medications when they are prescribed as a single pack. It is strongly recommended that the 'Medication item' be coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available. Terminology: SNOMED-CT Interferon alfa Lopinavir Ritonavir Ribavirin Methylprednisolone Chloroquine phosphate Glucocorticoid Tocilizumab Gamma globulin
Route	Route: The route by which the ordered item is to be administered into the subject's body. For example: 'oral', 'intravenous', or 'topical'. Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.
Clinical indication	Clinical indication: The clinical reason for use of the ordered item. For example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. It is not intended to carry an indication for administrative authorisation purposes.
Discharge	Discharge: A generic section header which should be renamed in a template to suit a specific clinical context.
Discharge criteria	Discharge criteria: Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.
Data
Health risk	Health risk: Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name. Coding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia. Terminology: SNOMED-CT Medically fit for discharge
Clinical factors	Clinical factors: Details about each possible risk factor.
Factor	Factor: Identification of the risk factor, by name. For example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of 'Risk factor' with a terminology, where possible. Body temperature normal for more than 3 days Respiratory symptoms improved Chest x-ray shows absorption of inflammation Nucleic acid tests negative on 2 consecutive samples, at least 24 hours apart
Presence	Presence: Presence of the risk factor. Present Indeterminate Absent
Discharge assessment	Discharge assessment: Evaluation of the health risk. There may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number. Fit for discharge Not fit for discharge
Protocol
Last updated	Last updated: The date this health risk assessment was last updated. This data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician.
Conclusion	Conclusion: A generic section header which should be renamed in a template to suit a specific clinical context.
COVID-19 diagnosis	COVID-19 diagnosis: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Problem/Diagnosis name	Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible. Terminology: SNOMED_CT Pneumonia caused by SARS-CoV-2 Acute respiratory distress syndrome caused by SARS-CoV-2 Lower respiratory infection caused by SARS-CoV-2 Acute bronchitis caused by SARS-CoV-2 Lymphocytopenia associated with severe acute respiratory syndrome coronavirus 2 Thrombocytopenia associated with severe acute respiratory syndrome coronavirus 2
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT. Mild Moderate Severe Critical
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Other diagnosis	Other diagnosis: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Problem/Diagnosis name	Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Severity	Severity: An assessment of the overall severity of the problem or diagnosis. If severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT. Coded Text Mild Moderate Severe Text
Protocol
Last updated	Last updated: The date this problem or diagnosis was last updated.
Other contributors	Heather Leslie; Shan Nan; Mengyang Li; Hailing Cai; Bin Qi; Tianhua Tang<11915018@zju.edu.cn>; Hongshuo Feng<21915015@zju.edu.cn>