EHDS refined base model for Laboratory result report

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Author(s) by whom the laboratory result report was authored. Multiple authors could be provided.

Author of the laboratory report could be either a health professional who authored the report, laboratory itself or laboratory information system. Author information is the only mandatory element of the laboratory report header. As such, each laboratory shall be able to provide at least the author information.

Date and optionally time of authoring/issuing

Status of the resource or document

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Type of document at hand, e.g. 60591-5 Patient summary document.

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time of service that is being documented

Business version of the document. The exact algorithm for versioning is decided by the producer/custodian.

Document attestation details

Attester who validated laboratory result report. Multiple attesters could be provided.

Attestation (validation) of the laboratory report content is the usual step before legal authentication. Attestation could be provided by e.g. the laboratory specialist or the laboratory information system based on internal rules of the laboratory.

Date and time of the approval of the document by Attester.

Document legal authentication details

The person or organization taking responsibility for the medical content of the document

Legal authentication of the laboratory report is the usual step after attestation. Legal authentication could be provided by e.g. the head of the laboratory or the laboratory organization itself.

Date and time when the document was authorised.

Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

SNOMED CT

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Health insurance and payment information

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Laboratory Report structured body

Order Information (Laboratory Result Report could respond to multiple test orders)

An identifier of the laboratory test order. Laboratory Result Report may respond to multiple orders.

Date and time of the order placement.

The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.

An explanation or justification for why this service is being requested in textual form.

An explanation or justification for why this service is being requested in coded form.

SNOMED CT

Specification of clinical question (goal of the investigation) to be answered by the laboratory investigation.

Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as 'ask at order entry questions (AOEs).' This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements.

Clinical findings and other observations.

Condition that may influence the service or result interpretation.

Medication administered before ordering the service.

A Sex Parameter for Clinical Use is a parameter that provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc.. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population

HL7 sex-parameter-for-clinical-use

Vaccination history of the patient.

Any other type of relevant supporting information

Specimen information

Specification of requested service or services

Laboratory report result data

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

Observation details (report could consist of multiple observations)

Report attachments data elements

EHDS refined base model for Laboratory result report

Author(s) by whom the laboratory result report was authored. Multiple authors could be provided.

Author of the laboratory report could be either a health professional who authored the report, laboratory itself or laboratory information system. Author information is the only mandatory element of the laboratory report header. As such, each laboratory shall be able to provide at least the author information.

Attester who validated laboratory result report. Multiple attesters could be provided.

Attestation (validation) of the laboratory report content is the usual step before legal authentication. Attestation could be provided by e.g. the laboratory specialist or the laboratory information system based on internal rules of the laboratory.

The person or organization taking responsibility for the medical content of the document

Legal authentication of the laboratory report is the usual step after attestation. Legal authentication could be provided by e.g. the head of the laboratory or the laboratory organization itself.

SNOMED CT

Health insurance and payment information

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Laboratory Report structured body

Order Information (Laboratory Result Report could respond to multiple test orders)

An identifier of the laboratory test order. Laboratory Result Report may respond to multiple orders.

Date and time of the order placement.

The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.

An explanation or justification for why this service is being requested in textual form.

An explanation or justification for why this service is being requested in coded form.

SNOMED CT

Specification of clinical question (goal of the investigation) to be answered by the laboratory investigation.

Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as 'ask at order entry questions (AOEs).' This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements.

Clinical findings and other observations.

Condition that may influence the service or result interpretation.

Medication administered before ordering the service.

A Sex Parameter for Clinical Use is a parameter that provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc.. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population

HL7 sex-parameter-for-clinical-use

Vaccination history of the patient.

Any other type of relevant supporting information

Specimen information

Specification of requested service or services

Laboratory report result data

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

Observation details (report could consist of multiple observations)

Report attachments data elements

EHDS refined base model for Laboratory result report

Basic metadata for this information

Patient/subject information

Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).

Author(s) by whom the laboratory result report was authored. Multiple authors could be provided.

Author of the laboratory report could be either a health professional who authored the report, laboratory itself or laboratory information system. Author information is the only mandatory element of the laboratory report header. As such, each laboratory shall be able to provide at least the author information.

Date and optionally time of authoring/issuing

Status of the resource or document

Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Type of document at hand, e.g. 60591-5 Patient summary document.

LOINC

Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'

Time of service that is being documented

Business version of the document. The exact algorithm for versioning is decided by the producer/custodian.

Document attestation details

Attester who validated laboratory result report. Multiple attesters could be provided.

Attestation (validation) of the laboratory report content is the usual step before legal authentication. Attestation could be provided by e.g. the laboratory specialist or the laboratory information system based on internal rules of the laboratory.

Date and time of the approval of the document by Attester.

Document legal authentication details

The person or organization taking responsibility for the medical content of the document

Legal authentication of the laboratory report is the usual step after attestation. Legal authentication could be provided by e.g. the head of the laboratory or the laboratory organization itself.

Date and time when the document was authorised.

Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.

SNOMED CT

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Health insurance and payment information

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

Laboratory Report structured body

Order Information (Laboratory Result Report could respond to multiple test orders)

An identifier of the laboratory test order. Laboratory Result Report may respond to multiple orders.

Date and time of the order placement.

The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.

An explanation or justification for why this service is being requested in textual form.

An explanation or justification for why this service is being requested in coded form.

SNOMED CT

Specification of clinical question (goal of the investigation) to be answered by the laboratory investigation.

Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as 'ask at order entry questions (AOEs).' This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements.

Clinical findings and other observations.

Condition that may influence the service or result interpretation.

Medication administered before ordering the service.

A Sex Parameter for Clinical Use is a parameter that provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc.. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population

HL7 sex-parameter-for-clinical-use

Vaccination history of the patient.

Any other type of relevant supporting information

Specimen information

Specification of requested service or services

Laboratory report result data

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

Observation details (report could consist of multiple observations)

Report attachments data elements