Results data elements. Section A5 of the eHN guideline.

A.2.4.1 Laboratory report narrative

Entire report (textual summary inside the laboratory result report document) as issued by the laboratory.

Comments, such as a textual interpretation or advice accompanying the result report, for example.

A.2.4.2 Observation details (report could consist of multiple observations)

Date and time of the observation - Preferred system(s): ISO 8601

Code representing the observation using the agreed code systems.

• Preferred system(s): NČLP

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Very often the text is the same as a displayName of one of the codings.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Full name of the observation according to the used test coding standard.

Observation method (measurement principle) to obtain the result.

• Preferred system(s): SNOMED CT

Device (analyser), laboratory test kit and used calibrator information (identifier, type, name, model, manufacturer)

• Preferované systémy: SNOMED CT
• Preferované systémy: EMDN

Information about the test kit used – ID, type, name, manufacturer

Information about the calibrator used (unless it is a basic unit of measurement, e.g. IU) - ID, type, name, manufacturer

Identifies order and order placer this observation belongs to.

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document.

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

• Preferred system(s): SNOMED CT (for ordinal or nominal scale results and result interpretation)
• Preferred system(s): UCUM (for units)

Information about reference intervals and result interpretation.

• Preferred system(s): SNOMED CT

Comments and narrative representation of the observation result and findings.

Accreditation status of the laboratory for the particular observation.

Results data elements. Section A5 of the eHN guideline.

A.2.4.1 Laboratory report narrative

Entire report (textual summary inside the laboratory result report document) as issued by the laboratory.

Comments, such as a textual interpretation or advice accompanying the result report, for example.

A.2.4.2 Observation details (report could consist of multiple observations)

Date and time of the observation - Preferred system(s): ISO 8601

Code representing the observation using the agreed code systems.

• Preferred system(s): NČLP

Full name of the observation according to the used test coding standard.

Observation method (measurement principle) to obtain the result.

• Preferred system(s): SNOMED CT

Device (analyser), laboratory test kit and used calibrator information (identifier, type, name, model, manufacturer)

• Preferované systémy: SNOMED CT
• Preferované systémy: EMDN

Information about the test kit used – ID, type, name, manufacturer

Information about the calibrator used (unless it is a basic unit of measurement, e.g. IU) - ID, type, name, manufacturer

Identifies order and order placer this observation belongs to.

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document.

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

• Preferred system(s): SNOMED CT (for ordinal or nominal scale results and result interpretation)
• Preferred system(s): UCUM (for units)

Information about reference intervals and result interpretation.

• Preferred system(s): SNOMED CT

Comments and narrative representation of the observation result and findings.

Accreditation status of the laboratory for the particular observation.

Results data elements. Section A5 of the eHN guideline.

A.2.4.1 Laboratory report narrative

Entire report (textual summary inside the laboratory result report document) as issued by the laboratory.

Comments, such as a textual interpretation or advice accompanying the result report, for example.

A.2.4.2 Observation details (report could consist of multiple observations)

Date and time of the observation - Preferred system(s): ISO 8601

Code representing the observation using the agreed code systems.

• Preferred system(s): NČLP

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A reference to a code defined by a terminology system.

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Allows for alternative encodings within a code system, and translations to other code systems.

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Very often the text is the same as a displayName of one of the codings.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Full name of the observation according to the used test coding standard.

Observation method (measurement principle) to obtain the result.

• Preferred system(s): SNOMED CT

Device (analyser), laboratory test kit and used calibrator information (identifier, type, name, model, manufacturer)

• Preferované systémy: SNOMED CT
• Preferované systémy: EMDN

Information about the test kit used – ID, type, name, manufacturer

Information about the calibrator used (unless it is a basic unit of measurement, e.g. IU) - ID, type, name, manufacturer

Identifies order and order placer this observation belongs to.

Identifies the originator/author and provides provenance information about the source of the results data that may have not originated with the source of the whole Laboratory Report document.

With certain observation results, e.g. there may also be an interpreter or a person responsible for validation.

Result of the observation including text, numeric and coded results of the measurement and measurement uncertainty. Content of the observation result will vary according to the type of the observation.

• Preferred system(s): SNOMED CT (for ordinal or nominal scale results and result interpretation)
• Preferred system(s): UCUM (for units)

Information about reference intervals and result interpretation.

• Preferred system(s): SNOMED CT

Comments and narrative representation of the observation result and findings.

Accreditation status of the laboratory for the particular observation.