HL7 Czech Laboratory Order IG
0.0.1 - ci-build

HL7 Czech Laboratory Order IG, published by HL7 Czech Republic. This guide is not an authorized publication; it is the continuous build for version 0.0.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-cz/lab-order/ and changes regularly. See the Directory of published versions

## Logical Model: LabOrderClinicalInformationCz - Detailed Descriptions

Page standards status: Draft | Maturity Level: 1

Definitions for the ClinicalInformationCz logical model.

- Key Elements Table
- Differential Elements Table
- Snapshot Elements Table

Guidance on how to interpret the contents of this table can be foundhere

0. ClinicalInformationCz
Definition | Information and data communicated to the laboratory affecting the execution of the order or the interpretation of the results
Short | A.2.7 - Clinical information (anamnesis)
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. ClinicalInformationCz.clinicalInfoText
Definition | Clinical information necessary for proper ordering or interpretation of results.
Short | A.2.7.1 - Clinical information in free text
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
4. ClinicalInformationCz.clinicalInfoFormalized
Definition | Clinical information (medical history) formalized
Short | A.2.7.2 - Clinical information (medical history) formalized
Control | 0..1
Type | CodeableConcept
6. ClinicalInformationCz.description
Definition | Diagnosis and other clinical information affecting the course or outcome of the examination. Preferred system(s): MKN-10 Preferred system(s): Orphacode
Short | A.2.7.3 - Description of the problem/diagnosis/condition
Control | 0..*
Type | CodeableConcept
8. ClinicalInformationCz.medication
Definition | A medication block containing information about medications that affect the course or result of the test or its interpretation. Preferred system(s): DLP Preferred system(s): ATC
Short | A.2.7.4 - Medications
Control | 0..*
Type | CodeableConcept
10. ClinicalInformationCz.vaccination
Definition | Vaccinations
Short | A.2.7.5 - Vaccinations
Control | 0..*
Type | CodeableConcept
12. ClinicalInformationCz.finding
Definition | Physical examination of the patient (systolic and diastolic blood pressure, heart rate, saturation, respiratory rate, current body temperature)
Short | A.2.7.6 - Physical findings
Control | 0..*
Type | CodeableConcept
14. ClinicalInformationCz.hospitalizationDate
Definition | Date of patient hospitalization
Short | A.2.7.7 - Date of hospitalization
Control | 0..*
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. ClinicalInformationCz.urgentInformation
Definition | Urgent information block in the same structure as other document types (discharge report, patient summary)
Short | A.2.7.8 - Urgent information
Control | 0..1
Type | Base
18. ClinicalInformationCz.urgentInformation.allergies
Definition | Allergies and intolerances that may affect order execution or interpretation of results
Short | A.2.7.8.1 - Allergies and intolerances
Control | 1..*
Type | CodeableConcept
20. ClinicalInformationCz.urgentInformation.warnings
Definition | Warnings and cautions that may affect order execution or interpretation of results
Short | A.2.7.8.2 - Warnings
Control | 0..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
22. ClinicalInformationCz.additionalData
Definition | A.2.7.9 - Additional formalised data
Short | A.2.7.9 - Additional formalised data
Control | 0..1
Type | Base
24. ClinicalInformationCz.additionalData.date
Definition | Date of discovery of the data, to be indicated if different from the date of the order.
Short | A.2.7.9.1 - Date
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
26. ClinicalInformationCz.additionalData.code
Definition | Observation code identifying the significance of the data (height, weight, week of gestation, etc.) Preferred system(s): NČLP Preferred system(s): SNOMED CT
Short | A.2.7.9.2 - Code
Control | 1..1
Type | CodeableConcept
28. ClinicalInformationCz.additionalData.value
Definition | Data value including unit of measurement.
Short | A.2.7.9.3 - Data value
Control | 0..1
Type | Narrative

Guidance on how to interpret the contents of this table can be foundhere

0. ClinicalInformationCz
Definition | Information and data communicated to the laboratory affecting the execution of the order or the interpretation of the results
Short | A.2.7 - Clinical information (anamnesis)
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. ClinicalInformationCz.clinicalInfoText
Definition | Clinical information necessary for proper ordering or interpretation of results.
Short | A.2.7.1 - Clinical information in free text
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
4. ClinicalInformationCz.clinicalInfoFormalized
Definition | Clinical information (medical history) formalized
Short | A.2.7.2 - Clinical information (medical history) formalized
Control | 0..1
Type | CodeableConcept
6. ClinicalInformationCz.description
Definition | Diagnosis and other clinical information affecting the course or outcome of the examination. Preferred system(s): MKN-10 Preferred system(s): Orphacode
Short | A.2.7.3 - Description of the problem/diagnosis/condition
Control | 0..*
Type | CodeableConcept
8. ClinicalInformationCz.medication
Definition | A medication block containing information about medications that affect the course or result of the test or its interpretation. Preferred system(s): DLP Preferred system(s): ATC
Short | A.2.7.4 - Medications
Control | 0..*
Type | CodeableConcept
10. ClinicalInformationCz.vaccination
Definition | Vaccinations
Short | A.2.7.5 - Vaccinations
Control | 0..*
Type | CodeableConcept
12. ClinicalInformationCz.finding
Definition | Physical examination of the patient (systolic and diastolic blood pressure, heart rate, saturation, respiratory rate, current body temperature)
Short | A.2.7.6 - Physical findings
Control | 0..*
Type | CodeableConcept
14. ClinicalInformationCz.hospitalizationDate
Definition | Date of patient hospitalization
Short | A.2.7.7 - Date of hospitalization
Control | 0..*
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. ClinicalInformationCz.urgentInformation
Definition | Urgent information block in the same structure as other document types (discharge report, patient summary)
Short | A.2.7.8 - Urgent information
Control | 0..1
Type | Base
18. ClinicalInformationCz.urgentInformation.allergies
Definition | Allergies and intolerances that may affect order execution or interpretation of results
Short | A.2.7.8.1 - Allergies and intolerances
Control | 1..*
Type | CodeableConcept
20. ClinicalInformationCz.urgentInformation.warnings
Definition | Warnings and cautions that may affect order execution or interpretation of results
Short | A.2.7.8.2 - Warnings
Control | 0..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
22. ClinicalInformationCz.additionalData
Definition | A.2.7.9 - Additional formalised data
Short | A.2.7.9 - Additional formalised data
Control | 0..1
Type | Base
24. ClinicalInformationCz.additionalData.date
Definition | Date of discovery of the data, to be indicated if different from the date of the order.
Short | A.2.7.9.1 - Date
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
26. ClinicalInformationCz.additionalData.code
Definition | Observation code identifying the significance of the data (height, weight, week of gestation, etc.) Preferred system(s): NČLP Preferred system(s): SNOMED CT
Short | A.2.7.9.2 - Code
Control | 1..1
Type | CodeableConcept
28. ClinicalInformationCz.additionalData.value
Definition | Data value including unit of measurement.
Short | A.2.7.9.3 - Data value
Control | 0..1
Type | Narrative

Guidance on how to interpret the contents of this table can be foundhere

0. ClinicalInformationCz
Definition | Information and data communicated to the laboratory affecting the execution of the order or the interpretation of the results
Short | A.2.7 - Clinical information (anamnesis)
Control | 0..*
Is Modifier | false
Logical Model | Instances of this logical model are not marked to be the target of a Reference
2. ClinicalInformationCz.clinicalInfoText
Definition | Clinical information necessary for proper ordering or interpretation of results.
Short | A.2.7.1 - Clinical information in free text
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
4. ClinicalInformationCz.clinicalInfoFormalized
Definition | Clinical information (medical history) formalized
Short | A.2.7.2 - Clinical information (medical history) formalized
Control | 0..1
Type | CodeableConcept
6. ClinicalInformationCz.description
Definition | Diagnosis and other clinical information affecting the course or outcome of the examination. Preferred system(s): MKN-10 Preferred system(s): Orphacode
Short | A.2.7.3 - Description of the problem/diagnosis/condition
Control | 0..*
Type | CodeableConcept
8. ClinicalInformationCz.medication
Definition | A medication block containing information about medications that affect the course or result of the test or its interpretation. Preferred system(s): DLP Preferred system(s): ATC
Short | A.2.7.4 - Medications
Control | 0..*
Type | CodeableConcept
10. ClinicalInformationCz.vaccination
Definition | Vaccinations
Short | A.2.7.5 - Vaccinations
Control | 0..*
Type | CodeableConcept
12. ClinicalInformationCz.finding
Definition | Physical examination of the patient (systolic and diastolic blood pressure, heart rate, saturation, respiratory rate, current body temperature)
Short | A.2.7.6 - Physical findings
Control | 0..*
Type | CodeableConcept
14. ClinicalInformationCz.hospitalizationDate
Definition | Date of patient hospitalization
Short | A.2.7.7 - Date of hospitalization
Control | 0..*
Type | dateTime
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
16. ClinicalInformationCz.urgentInformation
Definition | Urgent information block in the same structure as other document types (discharge report, patient summary)
Short | A.2.7.8 - Urgent information
Control | 0..1
Type | Base
18. ClinicalInformationCz.urgentInformation.allergies
Definition | Allergies and intolerances that may affect order execution or interpretation of results
Short | A.2.7.8.1 - Allergies and intolerances
Control | 1..*
Type | CodeableConcept
20. ClinicalInformationCz.urgentInformation.warnings
Definition | Warnings and cautions that may affect order execution or interpretation of results
Short | A.2.7.8.2 - Warnings
Control | 0..*
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
22. ClinicalInformationCz.additionalData
Definition | A.2.7.9 - Additional formalised data
Short | A.2.7.9 - Additional formalised data
Control | 0..1
Type | Base
24. ClinicalInformationCz.additionalData.date
Definition | Date of discovery of the data, to be indicated if different from the date of the order.
Short | A.2.7.9.1 - Date
Control | 0..1
Type | date
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
26. ClinicalInformationCz.additionalData.code
Definition | Observation code identifying the significance of the data (height, weight, week of gestation, etc.) Preferred system(s): NČLP Preferred system(s): SNOMED CT
Short | A.2.7.9.2 - Code
Control | 1..1
Type | CodeableConcept
28. ClinicalInformationCz.additionalData.value
Definition | Data value including unit of measurement.
Short | A.2.7.9.3 - Data value
Control | 0..1
Type | Narrative