CH LAB-Report (R4)
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CH LAB-Report (R4), published by HL7 Switzerland. This guide is not an authorized publication; it is the continuous build for version 1.0.0-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-report/ and changes regularly. See the Directory of published versions

Example Bundle: Bundle 1-tvt

Document Details

Generated Narrative: Bundle Laboratory Report - 10 March, 2023 14:30

Last updated: 2023-08-18 01:43:30+0000

Profiles: CH LAB Document: Laboratory Report, Bundle: Laboratory Report

Final Document at 2023-03-09 14:30:00+0100 by Dr. Eva Erlenmeyer for Hans Guggindieluft


Document Subject

id: HansGuggindieluft

meta:

identifier: 012/08.111111

name: Hans Guggindieluft

gender: MALE

birthDate: Jan 01, 1981

maritalStatus: unverheiratet (Details : {$ech-11-maritalstatus code '5' = '5', given as 'unverheiratet'})

Communications

-LanguagePreferred
*Deutsch (Schweiz) (Details : {urn:ietf:bcp:47 code 'de-CH' = 'German (Region=Schweiz))true

Document Content

Case study 1-tvt

Suspicion 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, 01.01.1984. 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.


Laboratory examinations

Hematology studies (set)

Chemistry studies (set)

Coagulation studies (set)


Additional Resources Included in Document


Entry 1 - fullUrl = urn:uuid:3dd8d097-67d0-4e39-aa68-5ab6fc13169c

Resource Composition:

Case study 1-tvt

Suspicion 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, 01.01.1984. 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.


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Resource DiagnosticReport:

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Laboratory report

SubjectNot done yet
When For2022-10-25 13:35:00+0100
Performer Dr. Eva Erlenmeyer
Identifier URI/urn:uuid:3f69e0a5-2177-4540-baab-7a5d0877428f

Report Details

CodeValue

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Resource Patient:

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meta:

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name: Hans Guggindieluft

gender: MALE

birthDate: Jan 01, 1981

maritalStatus: unverheiratet (Details : {$ech-11-maritalstatus code '5' = '5', given as 'unverheiratet'})

Communications

-LanguagePreferred
*Deutsch (Schweiz) (Details : {urn:ietf:bcp:47 code 'de-CH' = 'German (Region=Schweiz))true

Entry 4 - fullUrl = urn:uuid:0ad0810e-6eb4-11ee-b962-0242ac120002

Resource Observation:

Generated Narrative: Observation 0ad0810e-6eb4-11ee-b962-0242ac120002

status: Final

category: Laboratory, Hematopathology, Hematology studies (set)

code: CBC panel Auto (Bld)

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

specimen: Blood Sample

device: Sysmex XP-300

hasMember:


Entry 5 - fullUrl = urn:uuid:5c1ceea1-2751-4ddc-afb5-4c28037ba1be

Resource Observation:

Generated Narrative: Observation 5c1ceea1-2751-4ddc-afb5-4c28037ba1be

status: Final

category: Laboratory, Hematopathology, Hematology studies (set)

code: WBC Auto (Bld) [#/Vol]

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

value: 10 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')

method: Automated count technique (qualifier value)

ReferenceRanges

-LowHighType
*4.5 10*3/uL11 10*3/uLNormal Range

Entry 6 - fullUrl = urn:uuid:04ec7690-a1e8-4fdf-be4f-6c92949e948a

Resource Observation:

Generated Narrative: Observation 04ec7690-a1e8-4fdf-be4f-6c92949e948a

status: Final

category: Laboratory, Hematopathology, Hematology studies (set)

code: RBC Auto (Bld) [#/Vol]

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

value: 4.58 10*6/uL (Details: UCUM code10*6/uL = '10*6/uL')

method: Automated count technique (qualifier value)

ReferenceRanges

-LowHighType
*4.1 10*6/uL6.1 10*6/uLNormal Range

Entry 7 - fullUrl = urn:uuid:2565be07-47a0-4cca-926e-a57e1ac96fb8

Resource Observation:

Generated Narrative: Observation 2565be07-47a0-4cca-926e-a57e1ac96fb8

status: Final

category: Laboratory, Hematopathology, Hematology studies (set)

code: Hemoglobin (Bld) [Mass/Vol]

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

value: 10.8 umol/L (Details: UCUM codeumol/L = 'umol/L')

method: Photometry technique (qualifier value)

specimen: Blood sammple

ReferenceRanges

-LowHigh
*8.7 umol/L11.2 umol/L

Entry 8 - fullUrl = urn:uuid:c4d64c0a-aafb-4b41-ae0b-a620b2a6c08c

Resource Observation:

Generated Narrative: Observation c4d64c0a-aafb-4b41-ae0b-a620b2a6c08c

status: Final

category: Laboratory, Hematopathology, Hematology studies (set)

code: Hematocrit Auto (Bld) [Volume fraction]

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

value: 43 % (Details: UCUM code% = '%')

specimen: Blood sammple

ReferenceRanges

-LowHighType
*38 %46 %Normal Range

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Resource Observation:

Generated Narrative: Observation 857cfa10-66ea-45ae-b236-e6e03af4be3f

status: Final

category: Laboratory, Hematopathology, Hematology studies (set)

code: MCV Auto (RBC) [Entitic vol]

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

value: 85 fL (Details: UCUM codefL = 'fL')

ReferenceRanges

-LowHighType
*82.4 fL87.3 fLNormal Range

Entry 10 - fullUrl = urn:uuid:3b263f29-44d8-468f-b612-e748442e1845

Resource Observation:

Generated Narrative: Observation 3b263f29-44d8-468f-b612-e748442e1845

status: Final

category: Laboratory, Hematopathology, Hematology studies (set)

code: MCH Auto (RBC) [Entitic mass]

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

value: 30 pg (Details: UCUM codepg = 'pg')

ReferenceRanges

-LowHighType
*38 pg46 pgNormal Range

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Resource Observation:

Generated Narrative: Observation 735c9244-497a-420d-b006-15a57be365b1

status: Final

category: Laboratory, Hematopathology, Hematology studies (set)

code: MCHC Auto (RBC) [Mass/Vol]

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

value: 34.7 g/dL (Details: UCUM codeg/dL = 'g/dL')

ReferenceRanges

-LowHighType
*30 g/dL34 g/dLNormal Range

Entry 12 - fullUrl = urn:uuid:32a7d6fb-dc8a-4673-8cef-c59c1c5397db

Resource Observation:

Generated Narrative: Observation 32a7d6fb-dc8a-4673-8cef-c59c1c5397db

status: Final

category: Laboratory, Hematopathology, Hematology studies (set)

code: Platelets Auto (Bld) [#/Vol]

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

value: 200 10*3/uL (Details: UCUM code10*3/uL = '10*3/uL')

ReferenceRanges

-LowHighType
*150 10*3/uL450 10*3/uLNormal Range

Entry 13 - fullUrl = urn:uuid:c0eeeb40-77ed-46f3-b8d6-5fdac0a61f7c

Resource Observation:

Generated Narrative: Observation c0eeeb40-77ed-46f3-b8d6-5fdac0a61f7c

status: Final

category: Laboratory, Chemical pathology, Chemistry studies (set)

code: CRP [Mass/Vol]

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

value: 8 mg/L (Details: UCUM codemg/L = 'mg/L')

method: Turbidimetry technique (qualifier value)

specimen: Serum Sample

device: Afinion™ CRP Test

ReferenceRanges

-High
*10 mg/L

Entry 14 - fullUrl = urn:uuid:f30d8df7-474f-401e-b5d4-f690d28d718d

Resource Observation:

Generated Narrative: Observation f30d8df7-474f-401e-b5d4-f690d28d718d

status: Final

category: Laboratory, Hematopathology, Hematology studies (set)

code: Fibrin D-dimer FEU IA (Bld) [Mass/Vol]

subject: Hans Guggindieluft

effective: 2024-04-23 11:24:26+0100

performer: Eva Erlenmeyer

value: 1.8 mg/L (Details: UCUM codemg/L = 'mg/L')

interpretation: Critical high

method: Immunoassay technique (qualifier value)

specimen: Blood Sample Coagulation

device: Roche CARDIAC D-Dimer Testkit

ReferenceRanges

-High
*0.5 mg/L

Entry 15 - fullUrl = urn:uuid:3a98a13d-cf64-40bb-b7a0-87ef45193a74

Resource Specimen:

Generated Narrative: Specimen 3a98a13d-cf64-40bb-b7a0-87ef45193a74

status: Available

type: Blood specimen

subject: Hans Guggindieluft

Collections

-CollectorCollected[x]BodySite
*Dr. med. Marc Mustermann2024-04-16 06:40:17+0000No 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 = urn:uuid:8d38e1bd-dced-45c1-8978-949d6cfd21e8

Resource Specimen:

Generated Narrative: Specimen 8d38e1bd-dced-45c1-8978-949d6cfd21e8

identifier: 48736-55555-75465

accessionIdentifier: 4e88a-66666-dd888

status: Available

type: Blood specimen

subject: Hans Guggindieluft

receivedTime: 2020-08-16 16:40:17+0000

Collections

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Processings

-Time[x]
*2024-04-16 06:40:17+0000 --> 2024-04-17 06:40:17+0000

container


Entry 17 - fullUrl = urn:uuid:9b554309-f9d4-4559-ba81-91659cd11786

Resource Specimen:

Generated Narrative: Specimen 9b554309-f9d4-4559-ba81-91659cd11786

identifier: 48736-12345-75465

accessionIdentifier: 4e88a-12345-dd888

status: Available

type: Serum specimen

subject: Hans Guggindieluft

Collections

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*Bundle: identifier = http://example.org#e65fa2fa-c130-4097-9848-486ee61f58df; type = document; timestamp = 2023-03-09 14:30:00+01002024-04-16 06:40:17+0000No display for Specimen.collection.bodySite (concept: Structure of median cubital vein (body structure))Patient was fasting prior to the procedure.

container


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Resource Device:

Generated Narrative: Device 3b9c6849-cf71-45e9-9d88-31f7879342f0

identifier: http://www.labor-gantenbein.ch/devices/id/345675

UdiCarriers

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status: Active

manufacturer: Sysmex

lotNumber: lot.112233

serialNumber: 06882382


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Resource Device:

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identifier: http://www.labor-gantenbein.ch/devices/id/345675

UdiCarriers

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status: Active

manufacturer: Abbott

lotNumber: lot.112233

serialNumber: 1116787


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Resource Device:

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identifier: http://www.labor-gantenbein.ch/devices/id/345675

UdiCarriers

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lotNumber: lot.112233

serialNumber: 06882382


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Resource ServiceRequest:

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subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Blood Sample


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Resource ServiceRequest:

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requisition: Provider number/ReqID-1234567

status: Active

intent: Original Order

priority: Urgent

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subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Blood Sample


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Resource ServiceRequest:

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identifier: Placer Identifier/123

requisition: Provider number/ReqID-1234567

status: Active

intent: Original Order

priority: Urgent

code: No display for ServiceRequest.code (concept: Erythrocytes [#/volume] in Blood by Automated count)

subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Blood Sample


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Resource ServiceRequest:

Generated Narrative: ServiceRequest ce16707a-b9bb-4c8d-8e4e-f8c135ed4a40

identifier: Placer Identifier/123

requisition: Provider number/ReqID-1234567

status: Active

intent: Original Order

priority: Urgent

code: No display for ServiceRequest.code (concept: Hemoglobin [Mass/volume] in Blood)

subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Blood Sample


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Resource ServiceRequest:

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identifier: Placer Identifier/123

requisition: Provider number/ReqID-1234567

status: Active

intent: Original Order

priority: Urgent

code: No display for ServiceRequest.code (concept: Hematocrit [Volume Fraction] of Blood by Automated count)

subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Blood Sample


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Resource ServiceRequest:

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identifier: Placer Identifier/123

requisition: Provider number/ReqID-1234567

status: Active

intent: Original Order

priority: Urgent

code: No display for ServiceRequest.code (concept: MCV [Entitic volume] by Automated count)

subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Blood Sample


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Resource ServiceRequest:

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identifier: Placer Identifier/123

requisition: Provider number/ReqID-1234567

status: Active

intent: Original Order

priority: Urgent

code: No display for ServiceRequest.code (concept: MCH [Entitic mass] by Automated count)

subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Blood Sample


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Resource ServiceRequest:

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requisition: Provider number/ReqID-1234567

status: Active

intent: Original Order

priority: Urgent

code: No display for ServiceRequest.code (concept: MCHC [Mass/volume] by Automated count)

subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Blood Sample


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Resource ServiceRequest:

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identifier: Placer Identifier/123

requisition: Provider number/ReqID-1234567

status: Active

intent: Original Order

priority: Urgent

code: No display for ServiceRequest.code (concept: Platelets [#/volume] in Blood by Automated count)

subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Blood Sample


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Resource ServiceRequest:

Generated Narrative: ServiceRequest 8d98f9d1-581b-4495-93aa-4a522fa30a6c

identifier: Placer Identifier/123

requisition: Provider number/ReqID-1234567

status: Active

intent: Original Order

priority: Urgent

code: No display for ServiceRequest.code (concept: C reactive protein [Mass/volume] in Serum or Plasma)

subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Serum specimen


Entry 31 - fullUrl = urn:uuid:e0330c6c-4f9b-46e7-8817-2ae5301f5d14

Resource ServiceRequest:

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identifier: Placer Identifier/123

requisition: Provider number/ReqID-1234567

status: Active

intent: Original Order

priority: Urgent

code: No display for ServiceRequest.code (concept: Fibrin D-dimer FEU [Mass/volume] in Blood by Immunoassay)

subject: Hans Guggindieluft

requester: Marc Mustermann at Arztpraxis

specimen: Blood Sample Coagulation


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Resource PractitionerRole:

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practitioner: Dr. med. Marc Mustermann

organization: Bundle: identifier = http://example.org#e65fa2fa-c130-4097-9848-486ee61f58df; type = document; timestamp = 2023-03-09 14:30:00+0100

code: Generalist Medical Practitioners


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Resource Practitioner:

Generated Narrative: Practitioner e23d6fa1-88bc-497c-a4df-eb3fa60eaa37

identifier: GLN/7601000050700, urn:oid:2.16.756.5.30.1.123.100.2.1.1/A123309

name: Marc Mustermann (Official)

telecom: ph: 033 333 22 11(Work), marc.mustermann@gruppenpraxis.ch

address: Doktorgasse 2 Messen 3254 CH

Qualifications

-Code
*Doctor of Medicine

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Resource Organization:

Generated Narrative: Organization 32c4c990-cedb-4999-998d-bab1d55db49f

identifier: GLN/7601000235503

name: Arztpraxis Messen

contact

telecom: +41555545566, info@arztpraxis.ch, http://www.arztpraxis.ch

address: Doktorgasse 2 Messen 3254 CH


Entry 35 - fullUrl = urn:uuid:12328339-f7d6-4bb6-80e4-89fd03ce5052

Resource Practitioner:

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identifier: GLN/7601000050717, urn:oid:2.16.756.5.30.1.123.100.2.1.1/A123315

name: Eva Erlenmeyer (Official)

telecom: ph: 033 444 55 66(Work), eva.erlenmeyer@labor-pipette.ch

address: Laborstrasse 23 Olten 4600 CH

Qualifications

-Code
*Doctor of Medicine

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Resource PractitionerRole:

Generated Narrative: PractitionerRole 8472931c-fbd0-437b-9ed1-4f66472c78b5

practitioner: Bundle: identifier = http://example.org#e65fa2fa-c130-4097-9848-486ee61f58df; type = document; timestamp = 2023-03-09 14:30:00+0100

organization: Bundle: identifier = http://example.org#e65fa2fa-c130-4097-9848-486ee61f58df; type = document; timestamp = 2023-03-09 14:30:00+0100

code: Medical and Pathology Laboratory Technicians


Entry 37 - fullUrl = urn:uuid:84483dc8-81d3-41cc-8d24-10c241279024

Resource Organization:

Generated Narrative: Organization 84483dc8-81d3-41cc-8d24-10c241279024

identifier: GLN/7601000234407

name: Labor Pipette

contact

telecom: +41223345566

address: Laborstrasse 23 Olten 4600 CH (work)

contact

name: Dr. Eva Erlenmeyer(Official)

telecom: eva.erlenmeyer@labor-pipette.ch

address: Laborstrasse 23 4. Stock Olten 4600 CH