Generated Narrative: StructureDefinition EHDSLaboratoryReport Name Flags Card. Type Description & Constraints EHDSLaboratoryReport 0..* EHDSDocument Laboratory report model Elements defined in Ancestors:header, header, presentedForm Instances of this logical model can be the target of a Reference #xD; header 1..1 Base Laboratory Report header #xD; author[x] 1..* EHDSHealthProfessional, EHDSOrganisation, EHDSDevice Author(s) by whom the laboratory result report was authored. #xD; attestation #xD; attester[x] 1..1 EHDSHealthProfessional, EHDSDevice Attester who validated the document. Multiple attesters could be provided. #xD; legalAuthentication #xD; legalAuthenticator[x] 1..1 EHDSHealthProfessional, EHDSOrganisation The person or organisation taking responsibility for the medical content of the document (typically the person who signs it) #xD; eventType 0..* CodeableConcept 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. Binding Description: (preferred): SNOMED CT #xD; intendedRecipient[x] 0..* Intended recipient #xD; intendedRecipientEHDSPatient EHDSPatient #xD; intendedRecipientEHDSRelatedPerson EHDSRelatedPerson #xD; intendedRecipientEHDSHealthProfessional EHDSHealthProfessional #xD; intendedRecipientEHDSOrganisation EHDSOrganisation #xD; intendedRecipientEHDSDevice EHDSDevice #xD; body 0..1 Base Laboratory Report structured body #xD; orderInformation 0..* Base Order Information (Laboratory Result Report could respond to multiple test orders) #xD; orderId 1..* Identifier An identifier of the laboratory test order. Laboratory Result Report may respond to multiple orders. #xD; orderDateAndTime 0..1 dateTime Date and time of the order placement. #xD; orderPlacer[x] 0..1 The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself. #xD; orderPlacerEHDSHealthProfessional EHDSHealthProfessional #xD; orderPlacerEHDSOrganisation EHDSOrganisation #xD; orderPlacerEHDSPatient EHDSPatient #xD; orderReasonText 0..* string An explanation or justification for why this service is being requested in textual form. #xD; orderReason[x] 0..* An explanation or justification for why this service is being requested in coded form. Binding Description: (preferred): SNOMED CT #xD; orderReasonCodeableConcept CodeableConcept #xD; orderReasonEHDSCondition EHDSCondition #xD; orderReasonEHDSObservation EHDSObservation #xD; clinicalQuestion 0..1 string Specification of clinical question (goal of the investigation) to be answered by the laboratory investigation. #xD; <a href="StructureDefinition-EHDSLaboratoryReport-definitions.html#EHDSLaboratoryReport.body.supportingInformation" title="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.">supportingInformation 0..1 Base 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. #xD; observation 0..* EHDSObservation Clinical findings and other observations. #xD; condition 0..* EHDSCondition Condition that may influence the service or result interpretation. #xD; medicationAdministration 0..* EHDSMedicationAdministration Medication administered before ordering the service. #xD; <a href="StructureDefinition-EHDSLaboratoryReport-definitions.html#EHDSLaboratoryReport.body.supportingInformation.sexForClinicalUse" title="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">sexForClinicalUse 0..1 CodeableConcept 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 Binding Description: (preferred): HL7 sex-parameter-for-clinical-use #xD; vaccination 0..* EHDSImmunisation Vaccination history of the patient. #xD; otherSupportingInformation 0..* Resource Any other type of relevant supporting information #xD; specimen 0..* EHDSSpecimen Specimen information #xD; serviceRequest 0..* EHDSServiceRequest Specification of requested service or services #xD; resultData 1..1 Base Laboratory report result data #xD; commentsInterpretationAndRecommendations 0..* Narrative Narrative Comments, such as a textual interpretation or advice accompanying the result report, for example. This profile does not constrain the narrative in regard to content, language, or traceability to data elements #xD; laboratoryTestResults 0..* EHDSLaboratoryObservation Observation details (report could consist of multiple observations) #xD; attachments[x] 0..* Report attachments data elements #xD; attachmentsEHDSAttachment EHDSAttachment #xD; attachmentsEHDSMedia EHDSMedia #xD; Documentation for this format
EHDS refined base model for Laboratory result report
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.
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
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.
Type of document at hand, e.g. 60591-5 Patient summary document.
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.
Attester who validated the document. Multiple attesters could be provided.
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.
The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
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.
Additional details about where the content was created (e.g. clinical specialty)
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
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
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.
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.
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
Any other type of relevant supporting information
Specification of requested service or services
Narrative Comments, such as a textual interpretation or advice accompanying the result report, for example.
Observation details (report could consist of multiple observations)