CH LAB-Order (R4)
3.0.0-ci-build - ci-build
CH LAB-Order (R4), published by HL7 Switzerland. This guide is not an authorized publication; it is the continuous build for version 3.0.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7ch/ch-lab-order/ and changes regularly. See the Directory of published versions
Document Details
Generated Narrative: Bundle Laboratory Order by Form 1-tvt
version: 1; Last updated: 2019-04-01 20:18:41+0000
Profile: CH ORF Document
Final Document at 2019-03-31 11:46:09+0200 by PractitionerRole for Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
Document Subject
Unable to resolve subject ''
Document Content
A patient, Tobias Timmermann, presents to Dr. med. Marc Mustermann at the Olten group practice on 09.03.2016. He verbally identifies himself via his master data as Tobias Timmermann, 01.01.1981. He reports unclear leg pain in the left lower leg as well as simultaneously occurring respiratory pain and cough. The doctor carries out the anamnesis and physical examination and prescribes the following laboratory parameters:
The doctor carries out the Blood count and the CRP determination himself by means of point of care diagnostics, the D-dimer diagnostics is prescribed as quantitative diagnostics in an external sending laboratory. To obtain the sample, a Blood sample is taken lying down (1 EDTA tube, 2 citrate tubes of 5 ml). The order is transmitted to the external laboratory and the sample is sent to the external dispatch laboratory by courier ordered by telephone. The results of the internal point of care diagnostics (Blood count and CRP) are entered in the patient`s laboratory sheet in the doctor`s office software (manually or via locally installed electronic interfaces). A prescription is therefore issued by the doctor to the patient for self-administration of an anti-thrombotic agent. The results of the sending-in laboratory arrive electronically at the GP`s on the same evening and are also entered in the patient`s laboratory sheet. By using the present exchange format, this process can be fully automated. After a telephone enquiry by the doctor at the sending laboratory due to a borderline D-dimer result, the information is given that a deep vein thrombosis cannot be ruled out in this situation by means of D-dimer and the patient is therefore called back the next day for a sonography of the legs.
As it is probably a primary leg vein thrombosis, Dr Eva Erlenmeier from the Pipette laboratory sends feedback to Dr Mustermann with the recommendation to carry out a thrombophilia screening, which includes the following analyses: Quick, aPTT, fibrinogen, antithrombin (funct.), thrombin time I 2.5 NIH/ml, APC resistance, D-dimers, protein C, (aPTT method), protein S antigen. The analyses can be carried out directly from the samples of the citrate tubes sent along.
Entry 1 - fullUrl = http://example.com/fhir/Composition/1-tvt-composition-with-sr-and-form
Resource Composition:
Case study 1Suspicion of deep vein thrombosis
A patient, Tobias Timmermann, presents to Dr. med. Marc Mustermann at the Olten group practice on 09.03.2016. He verbally identifies himself via his master data as Tobias Timmermann, 01.01.1981. He reports unclear leg pain in the left lower leg as well as simultaneously occurring respiratory pain and cough. The doctor carries out the anamnesis and physical examination and prescribes the following laboratory parameters:
- Blood cell count incl. differentiation
- CRP
- D-dimer
The doctor carries out the Blood count and the CRP determination himself by means of point of care diagnostics, the D-dimer diagnostics is prescribed as quantitative diagnostics in an external sending laboratory. To obtain the sample, a Blood sample is taken lying down (1 EDTA tube, 2 citrate tubes of 5 ml). The order is transmitted to the external laboratory and the sample is sent to the external dispatch laboratory by courier ordered by telephone. The results of the internal point of care diagnostics (Blood count and CRP) are entered in the patient`s laboratory sheet in the doctor`s office software (manually or via locally installed electronic interfaces). A prescription is therefore issued by the doctor to the patient for self-administration of an anti-thrombotic agent. The results of the sending-in laboratory arrive electronically at the GP`s on the same evening and are also entered in the patient`s laboratory sheet. By using the present exchange format, this process can be fully automated. After a telephone enquiry by the doctor at the sending laboratory due to a borderline D-dimer result, the information is given that a deep vein thrombosis cannot be ruled out in this situation by means of D-dimer and the patient is therefore called back the next day for a sonography of the legs.
As it is probably a primary leg vein thrombosis, Dr Eva Erlenmeier from the Pipette laboratory sends feedback to Dr Mustermann with the recommendation to carry out a thrombophilia screening, which includes the following analyses: Quick, aPTT, fibrinogen, antithrombin (funct.), thrombin time I 2.5 NIH/ml, APC resistance, D-dimers, protein C, (aPTT method), protein S antigen. The analyses can be carried out directly from the samples of the citrate tubes sent along.
Entry 2 - fullUrl = http://example.com/fhir/Patient/TobiasTimmermann
Resource Patient:
id: TobiasTimmermann
meta:
identifier: 012/08.111111
name: Tobias Timmermann
gender: MALE
birthDate: Jan 01, 1981
maritalStatus: unverheiratet (Details : {$ech-11-maritalstatus code '5' = '5', given as 'unverheiratet'})
Communications
- Language Preferred * Deutsch (Schweiz) (Details : {urn:ietf:bcp:47 code 'de-CH' = 'German (Region=Schweiz)) true
Entry 3 - fullUrl = http://example.com/fhir/Practitioner/MarcMustermann
Resource Practitioner:
Generated Narrative: Practitioner MarcMustermann
identifier: GLN/7601000050700,
urn:oid:2.16.756.5.30.1.123.100.2.1.1
/A123309name: Marc Mustermann (Official)
telecom: ph: 033 444 22 11(Work), marc.mustermann@gruppenpraxis.ch
Entry 4 - fullUrl = http://example.com/fhir/Organization/Gruppenpraxis
Resource Organization:
Generated Narrative: Organization Gruppenpraxis
identifier: GLN/7601000241115
name: Gruppenpraxis Olten
contact
telecom: +41555556677, info@gruppenpraxis.ch, http://www.gruppenpraxis.ch
address: Gerbergasse 12 Olten 4600 CH
Entry 5 - fullUrl = http://example.com/fhir/PractitionerRole/MarcMustermannGruppenpraxis
Resource PractitionerRole:
Generated Narrative: PractitionerRole MarcMustermannGruppenpraxis
practitioner: Practitioner Marc Mustermann (official)
organization: Organization Gruppenpraxis Olten
Entry 6 - fullUrl = http://example.com/fhir/Practitioner/PeterPresto
Resource Practitioner:
Generated Narrative: Practitioner PeterPresto
identifier: GLN/7601022050702,
urn:oid:2.16.756.5.30.1.123.100.2.1.1
/A123303name: Peter Presto (Official)
telecom: ph: 032 333 22 33(Work), peter.presto@arztpraxis.ch
Entry 7 - fullUrl = http://example.com/fhir/PractitionerRole/PeterPrestoGruppenpraxis
Resource PractitionerRole:
Generated Narrative: PractitionerRole PeterPrestoGruppenpraxis
practitioner: Practitioner Peter Presto (official)
organization: Organization Gruppenpraxis Olten
Entry 8 - fullUrl = http://example.com/fhir/Practitioner/EvaErlenmeyer
Resource Practitioner:
Generated Narrative: Practitioner EvaErlenmeyer
identifier: GLN/7601000050717,
urn:oid:2.16.756.5.30.1.123.100.2.1.1
/A123315name: Eva Erlenmeyer (Official)
telecom: ph: 033 444 55 66(Work), eva.erlenmeyer@labor-pipette.ch
Entry 9 - fullUrl = http://example.com/fhir/Organization/LaborPipette
Resource Organization:
Generated Narrative: Organization LaborPipette
identifier: GLN/7601000234407
name: Labor Pipette
contact
telecom: +41223345566, info@labor-pipette.ch, http://www.labor-pipette.ch
address: Laborstrasse 23 Olten 4600 CH
Entry 10 - fullUrl = http://example.com/fhir/PractitionerRole/EvaErlenmeyerLaborPipette
Resource PractitionerRole:
Generated Narrative: PractitionerRole EvaErlenmeyerLaborPipette
identifier:
urn:oid:2.16.756.5.30.1.123.100.2.1.1
/A123444practitioner: Practitioner Eva Erlenmeyer (official)
organization: Organization Labor Pipette
Entry 11 - fullUrl = http://example.com/fhir/Coverage/HealthInsuranceCardTobiasTimmermann
Resource Coverage:
Generated Narrative: Coverage HealthInsuranceCardTobiasTimmermann
identifier: Insurance Card Number/A123456780-1
status: Active
type: According to KVG
subscriber: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
beneficiary: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
period: ?? --> 2024-12-31
Entry 12 - fullUrl = http://example.com/fhir/Condition/ConditionRenalInsufficiency
Resource Condition:
Generated Narrative: Condition ConditionRenalInsufficiency
clinicalStatus: Active
verificationStatus: Confirmed
category: diagnosis
severity: Mild to moderate (qualifier value)
code: Chronic renal insufficiency (disorder)
subject: Tobias Timmermann
onset: 2023-08-05
recordedDate: 2023-10-05
Entry 13 - fullUrl = http://example.com/fhir/Specimen/Serum-1-tvt
Resource Specimen:
Generated Narrative: Specimen Serum-1-tvt
identifier: 48736-12345-75465
accessionIdentifier: 4e88a-12345-dd888
status: Available
type: Serum specimen (specimen)
subject: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
Collections
Collector Collected[x] BodySite FastingStatus[x] Practitioner Marc Mustermann (official) 2015-08-16 06:40:17+0000 No display for Specimen.collection.bodySite (concept: Structure of median cubital vein (body structure)) Patient was fasting prior to the procedure. container
Entry 14 - fullUrl = http://example.com/fhir/Specimen/Blood-coag-1-tvt
Resource Specimen:
Generated Narrative: Specimen Blood-coag-1-tvt
identifier: 48736-55555-75465
accessionIdentifier: 4e88a-66666-dd888
status: Available
type: Blood sample
subject: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
receivedTime: 2023-12-01 16:40:17+0000
Collections
Collector Collected[x] Practitioner Marc Mustermann (official) 2023-12-01 17:00:17+0000 Processings
Time[x] 2023-12-01 17:00:17+0000 --> 2023-12-01 17:30:17+0000 container
Entry 15 - fullUrl = http://example.com/fhir/Specimen/Blood-1-tvt
Resource Specimen:
Generated Narrative: Specimen Blood-1-tvt
status: Available
type: Blood sample
subject: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
Collections
Collector Collected[x] BodySite Practitioner Marc Mustermann (official) 2015-08-16 06:40:17+0000 No display for Specimen.collection.bodySite (concept: Structure of superficial vein of left upper limb (body structure)) container
note: Specimen is grossly lipemic
Entry 16 - fullUrl = http://example.com/fhir/Questionnaire/1-tvt
Resource Questionnaire:
Generated Narrative: Questionnaire 1-tvt
version: 1; Last updated: 2023-06-06 20:17:53+0000
Profiles: CH ORF Questionnaire, SDCBaseQuestionnaire, Extractable Questionnaire - StructureMap
Entry 17 - fullUrl = http://example.com/fhir/QuestionnaireResponse/1-tvt
Resource QuestionnaireResponse:
Generated Narrative: QuestionnaireResponse 1-tvt
version: 1; Last updated: 2023-06-06 17:04:38+0000
Profile: CH ORF QuestionnaireResponse
LinkID Text Definition Answer 1-tvt Questionnaire:Lab Order Form Example 1-tvt order Auftrag order.placerOrderIdentifier Auftragsnummer des Auftraggebers 123 order.placerOrderIdentifierDomain Identifier Domain der Auftragsnummer des Auftraggebers urn:oid:2.16.756.5.30 order.precedentDocumentIdentifier Identifier des Vorgängerdokuments 1622f2fb-6ba3-4532-9aed-35b158def187 order.notificationContactDocument Dringender Benachrichtigungskontakt für dieses Dokument order.notificationContactDocument.practitioner Zu benachrichtigende Person order.notificationContactDocument.practitioner.title Titel Dr. med. order.notificationContactDocument.practitioner.familyName Name Erlenmeyer order.notificationContactDocument.practitioner.givenName Vorname Eva order.notificationContactDocument.practitioner.phone Telefon 033 444 55 66 order.notificationContactDocument.practitioner.email eva.erlenmeyer@labor-pipette.ch order.notificationContactDocumentResponse Dringender Benachrichtigungskontakt für die Antwort auf dieses Dokument order.notificationContactDocumentResponse.practitioner Zu benachrichtigende Person order.notificationContactDocumentResponse.practitioner.title Titel Dr. med. order.notificationContactDocumentResponse.practitioner.familyName Name Mustermann order.notificationContactDocumentResponse.practitioner.givenName Vorname Marc order.notificationContactDocumentResponse.practitioner.phone Telefon 033 444 55 66 order.notificationContactDocumentResponse.practitioner.email peter.presto@arztpraxis.ch order.priority Auftragspriorität RequestPriority routine: Routine receiver Empfänger receiver.practitioner Empfangende Person receiver.practitioner.title Titel Dr. med. receiver.practitioner.familyName Name Erlenmeyer receiver.practitioner.givenName Vorname Eva receiver.practitioner.gln GLN 7601000050703 receiver.practitioner.phone Telefon +41322552525 receiver.practitioner.email eva.erlenmeyer@labor-pipette.ch receiver.organization Empfangende Organisation receiver.organization.name Name der Organisation Labor Pipette receiver.organization.streetAddressLine Strasse, Hausnummer, Postfach etc. receiver.organization.postalCode PLZ 4600 receiver.organization.city Ort Olten receiver.organization.country Land Schweiz patient Patient patient.familyName Name Timmermann patient.maidenName Ledigname Bering patient.givenName Vorname Tobias patient.localPid Lokale Patienten-ID 11.22.33.5678 patient.birthDate Geburtsdatum 1984-01-01 patient.gender Geschlecht AdministrativeGender male: Male patient.maritalStatus Zivilstand eCH-011 MaritalStatus 5: unverheiratet patient.phone Telefon 079 979 79 79 patient.email erika@musterfrau.ch patient.streetAddressLine Strasse, Hausnummer, Postfach etc. patient.postalCode PLZ 8000 patient.city Ort Zürich patient.country Land Schweiz sender Absender sender.author Verantwortlicher sender.author.practitioner Verantwortliche Person sender.author.practitioner.title Titel Dr. med. sender.author.practitioner.familyName Name Mustermann sender.author.practitioner.givenName Vorname Marc sender.author.practitioner.gln GLN 7601000034321 sender.author.practitioner.zsr ZSR A123309 sender.author.practitioner.phone Telefon 033 333 22 11 sender.author.practitioner.email marc.mustermann@gruppenpraxis.ch sender.author.organization Verantwortliche Organisation sender.author.organization.name Name der Organisation Gruppenpraxis sender.author.organization.streetAddressLine Strasse, Hausnummer, Postfach etc. sender.author.organization.postalCode PLZ 4600 sender.author.organization.city Ort Olten sender.author.organization.country Land Schweiz sender.dataenterer Erfasser sender.dataenterer.practitioner Erfassende Person sender.dataenterer.practitioner.familyName Name Mustermann sender.dataenterer.practitioner.givenName Vorname Marc sender.dataenterer.practitioner.phone Telefon 033 333 22 11 sender.dataenterer.practitioner.email marc.mustermann@gruppenpraxis.ch receiverCopies Kopieempfänger receiverCopy Kopieempfangende Organisation oder Person receiverCopy.organization.name Name der Organisation Praxis Seeblick receiverCopy.title Titel Dr. med. receiverCopy.familyName Name Meier receiverCopy.givenName Vorname Sabine receiverCopy.phone Telefon 044 333 22 11 receiverCopy.email sabine.meier@praxisseeblick.ch receiverCopy Kopieempfangende Organisation oder Person receiverCopy.familyName Name Meier receiverCopy.givenName Vorname Sabine receiverCopy.phone Telefon 044 333 22 11 receiverCopy.email sabine.meier@praxis.ch receiverCopy.streetAddressLine Strasse, Hausnummer, Postfach etc. receiverCopy.postalCode PLZ 6330 receiverCopy.city Ort Cham receiverCopy.country Land Schweiz hematology Hematology hemato-subset Hämatologie Subset coagulation Coagulation d-dimer D-Dimer LOINC 55398-2: Short Fibrin D-dimer FEU and DDU panel - Platelet poor plasma cc clinical chemistry crp CRP LOINC 1988-5: C reactive protein [Mass/volume] in Serum or Plasma
Documentation for this format
Entry 18 - fullUrl = http://example.com/fhir/ServiceRequest/1-tvt-service-request-0
Resource ServiceRequest:
Generated Narrative: ServiceRequest 1-tvt-service-request-0
identifier: Placer Identifier/123
basedOn: ServiceRequest 25-Hydroxyvitamin D3+25-Hydroxyvitamin D2 [Mass/volume] in Serum or Plasma
status: Active
intent: Original Order
priority: Urgent
subject: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
requester: PractitionerRole
Entry 19 - fullUrl = http://example.com/fhir/ServiceRequest/1-tvt-service-request-1
Resource ServiceRequest:
Generated Narrative: ServiceRequest 1-tvt-service-request-1
identifier: Placer Identifier/123
status: Active
intent: Original Order
priority: Urgent
code: No display for ServiceRequest.code (concept: CBC panel - Blood by Automated count)
subject: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
requester: PractitionerRole
specimen: Specimen: status = available; type = Blood sample; note = Specimen is grossly lipemic
Entry 20 - fullUrl = http://example.com/fhir/ServiceRequest/1-tvt-service-request-2
Resource ServiceRequest:
Generated Narrative: ServiceRequest 1-tvt-service-request-2
identifier: Placer Identifier/123
status: Active
intent: Original Order
priority: Urgent
code: No display for ServiceRequest.code (concept: CBC W Auto Differential panel - Blood)
subject: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
requester: PractitionerRole
specimen: Specimen: status = available; type = Blood sample; note = Specimen is grossly lipemic
Entry 21 - fullUrl = http://example.com/fhir/ServiceRequest/1-tvt-service-request-3
Resource ServiceRequest:
Generated Narrative: ServiceRequest 1-tvt-service-request-3
identifier: Placer Identifier/123
status: Active
intent: Original Order
priority: Urgent
code: No display for ServiceRequest.code (concept: Short Fibrin D-dimer FEU and DDU panel - Platelet poor plasma)
subject: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
requester: PractitionerRole
Entry 22 - fullUrl = http://example.com/fhir/ServiceRequest/1-tvt-service-request-4
Resource ServiceRequest:
Generated Narrative: ServiceRequest 1-tvt-service-request-4
identifier: Placer Identifier/123
status: Active
intent: Original Order
priority: Urgent
code: No display for ServiceRequest.code (concept: C reactive protein [Mass/Volume] in Serum or Plasma)
subject: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
requester: PractitionerRole
specimen: Serum specimen
Entry 23 - fullUrl = http://example.com/fhir/ServiceRequest/1-tvt-service-request-5
Resource ServiceRequest:
Generated Narrative: ServiceRequest 1-tvt-service-request-5
identifier: Placer Identifier/123
status: Active
intent: Original Order
priority: Urgent
code: No display for ServiceRequest.code (concept: 25-Hydroxyvitamin D3+25-Hydroxyvitamin D2 [Mass/volume] in Serum or Plasma)
subject: Tobias Timmermann Male, DoB: 1984-01-01 ( Medical record number)
requester: PractitionerRole
supportingInfo: No display for ServiceRequest.supportingInfo (reference: ->Condition Chronic renal insufficiency (disorder))
specimen: Serum specimen