Generated Narrative: StructureDefinition GenericLaboratoryReport Name Flags Card. Type Description & Constraints GenericLaboratoryReport 0..* Element EHDS - Laboratory report Elements defined in Ancestors:@id, <a href="http://hl7.org/fhir/R4/datatypes.html#Element" title="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.">extension #xD; category 1..1 DvCodedText category Binding: EHDS - Laboratory report: category (required) #xD; <a href="StructureDefinition-GenericLaboratoryReport-definitions.html#GenericLaboratoryReport.composer" title="[RM] The person primarily responsible for the content of the Composition (but not necessarily its committal into the EHR system). This is the identifier which should appear on the screen. It may or may not be the person who entered the data. When it is the patient, the special self instance of `PARTY_SELF` will be used.">composer 1..1 PARTY_PROXY composer #xD; <a href="StructureDefinition-GenericLaboratoryReport-definitions.html#GenericLaboratoryReport.context" title="[RM] `COMPOSITION.context` - Documents the context information of a healthcare event involving the subject of care and the health system. The context information recorded here are independent of the attributes recorded in the version audit, which document the system interaction context, i.e. the context of a user interacting with the health record system. Healthcare events include patient contacts, and any other business activity, such as pathology investigations which take place on behalf of the patient.">context 1..1 EVENT_CONTEXT context #xD; startTime 1..1 DvDateTime start_time #xD; setting 1..1 DvCodedText setting Binding: EHDS - Laboratory report: setting (required) #xD; reportID 0..1 DvText Report ID #xD; recipient 0..1 Cluster Recipient #xD; name 0..1 DvText Name #xD; identifier 0..1 DvIdentifier Identifier #xD; organisation 0..1 Cluster Organisation #xD; name 0..1 DvText Name #xD; identifier 0..* DvIdentifier Identifier #xD; comment 0..1 DvText Comment #xD; xDSMetadata 0..1 Cluster XDS Metadata #xD; authorSpecialty 0..1 DvText Author specialty #xD; classCode 0..1 DvText Class code #xD; documentType 0..1 DvText Document type #xD; confidentialityCode 0..1 DvText Confidentiality code #xD; healthCareFacilityType 0..1 DvText Health care facility type #xD; practiceSettingCode 0..1 DvText Practice setting code #xD; eventCode 0..* DvText Event code #xD; documentMedia 0..1 DvMultimedia Document_media #xD; resultsInterpreter 0..1 Cluster Results interpreter #xD; name 0..1 DvText Name #xD; identifier 0..1 DvIdentifier Identifier #xD; organisation 0..1 Cluster Organisation #xD; name 0..1 DvText Name #xD; identifier 0..* DvIdentifier Identifier #xD; comment 0..1 DvText Comment #xD; ServiceRequest 0..1 INSTRUCTION Service request #xD; narrative 1..1 DvText narrative #xD; serviceName 1..1 DvText Service name #xD; reasonForRequest 0..* DvText Reason for request #xD; specimen 0..1 Cluster Specimen #xD; specimenType 0..1 DvText Specimen type #xD; anatomicalLocation 0..1 Cluster Anatomical location #xD; bodySiteName 1..1 DvText Body site name #xD; collectionDateTime[x] 0..1 Collection date/time #xD; collectionDateTimeDvDateTime DvDateTime #xD; collectionDateTimeDvInterval-DvDateTime DvInterval-DvDateTime #xD; timing 1..1 DvParsable Timing #xD; actionArchetypeId 1..1 string Action_archetype_id #xD; requesterOrderIdentifier[x] 0..1 Requester order identifier #xD; requesterOrderIdentifierDvText DvText #xD; requesterOrderIdentifierDvIdentifier DvIdentifier #xD; orderPlacer 0..1 Cluster Order placer #xD; name 0..1 DvText Name #xD; identifier 0..1 DvIdentifier Identifier #xD; organisation 0..1 Cluster Organisation #xD; name 0..1 DvText Name #xD; identifier 0..* DvIdentifier Identifier #xD; comment 0..1 DvText Comment #xD; receiverOrderIdentifier[x] 0..1 Receiver order identifier #xD; receiverOrderIdentifierDvText DvText #xD; receiverOrderIdentifierDvIdentifier DvIdentifier #xD; expiryTime 0..1 DvDateTime expiry_time #xD; LaboratoryTestResult 0..* OBSERVATION Laboratory test result #xD; time 1..1 DvDateTime time #xD; requestedTest 1..1 DvText Requested test #xD; specimen 0..* Cluster Specimen #xD; specimenType 0..1 DvText Specimen type #xD; collectionDateTime[x] 0..1 Collection date/time #xD; collectionDateTimeDvDateTime DvDateTime #xD; collectionDateTimeDvInterval-DvDateTime DvInterval-DvDateTime #xD; adequacyForTesting 0..1 DvCodedText Adequacy for testing Binding: EHDS - Laboratory report: Adequacy for testing (preferred) #xD; overallTestStatus 0..* DvCodedText Overall test status Binding: EHDS - Laboratory report: Overall test status (preferred) #xD; overallTestStatusTimestamp 0..1 DvDateTime Overall test status timestamp #xD; diagnosticServiceCategory 0..1 DvText Diagnostic service category #xD; clinicalInformationProvided 0..1 DvText Clinical information provided #xD; laboratoryAnalyteResult 0..* Cluster Laboratory analyte result #xD; analyteName 0..1 DvText Analyte name #xD; analyteResult[x] 0..1 Analyte result #xD; analyteResultDvQuantity DvQuantity #xD; analyteResultDvText DvText #xD; laboratoryAnalyteResultSubset 0..1 Cluster Laboratory analyte result subset #xD; analyteName 0..1 DvText Analyte name #xD; analyteResult[x] 0..1 Analyte result #xD; analyteResultDvQuantity DvQuantity #xD; analyteResultDvText DvText #xD; laboratoryAnalyteResultSubsubset 0..1 Cluster Laboratory analyte result subsubset #xD; analyteName 0..1 DvText Analyte name #xD; analyteResult[x] 0..1 Analyte result #xD; analyteResultDvQuantity DvQuantity #xD; analyteResultDvText DvText #xD; <a href="StructureDefinition-GenericLaboratoryReport-definitions.html#GenericLaboratoryReport.LaboratoryTestResult.laboratoryAnalyteResult.laboratoryAnalyteResultSubset.laboratoryAnalyteResultSubsubset.referenceRangeGuidance" title="[at0004] Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.">referenceRangeGuidance 0..1 DvText Reference range guidance #xD; status 0..1 DvCodedText status Binding: EHDS - Laboratory report: status (preferred) #xD; issued 0..1 DvDateTime Issued #xD; comment 0..1 DvText Comment #xD; referenceRangeGuidance 0..1 DvText Reference range guidance #xD; status 0..1 DvCodedText status Binding: EHDS - Laboratory report: status (preferred) #xD; issued 0..1 DvDateTime Issued #xD; comment 0..1 DvText Comment #xD; referenceRangeGuidance 0..1 DvText Reference range guidance #xD; status 0..1 DvCodedText status Binding: EHDS - Laboratory report: status (preferred) #xD; issued 0..1 DvDateTime Issued #xD; comment 0..1 DvText Comment #xD; conclusion 0..1 DvText Conclusion #xD; presentedForm 0..1 Cluster Presented form #xD; content 0..1 DvMultimedia Content #xD; contentName 0..1 DvText Content name #xD; identifier[x] 0..* Identifier #xD; identifierDvIdentifier DvIdentifier #xD; identifierDvText DvText #xD; created[x] 0..1 Created #xD; createdDvDateTime DvDateTime #xD; createdDvInterval-DvDateTime DvInterval-DvDateTime #xD; comment 0..1 DvText Comment #xD; performer 0..1 Cluster Performer #xD; name 0..1 DvText Name #xD; identifier 0..1 DvIdentifier Identifier #xD; testRequestDetails 0..1 Cluster Test request details #xD; placerOrderNumber 0..1 DvIdentifier Placer order number #xD; fillerOrderNumber 0..1 DvIdentifier Filler order number #xD; orderingProvider 0..1 Cluster Ordering provider #xD; orderinname 0..1 Cluster Name #xD; title 0..1 DvText Title #xD; givenName 0..1 DvText Given name #xD; familyName 0..1 DvText Family name #xD; identifier 0..1 DvIdentifier Identifier #xD; organisation 0..1 Cluster Organisation #xD; name 0..1 DvText Name #xD; identifier 0..* DvIdentifier Identifier #xD; comment 0..1 DvText Comment #xD; <a href="StructureDefinition-GenericLaboratoryReport-definitions.html#GenericLaboratoryReport.LaboratoryTestResult.labTestKit" title="[openEHR-EHR-CLUSTER.device.v1] An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.">labTestKit 0..1 Cluster Lab test kit #xD; deviceName 1..1 DvText Device name #xD; type 0..1 DvText Type #xD; uniqueDeviceIdentifierUDI 0..1 DvIdentifier Unique device identifier (UDI) #xD; manufacturer 0..1 DvText Manufacturer #xD; <a href="StructureDefinition-GenericLaboratoryReport-definitions.html#GenericLaboratoryReport.LaboratoryTestResult.referenceMaterial" title="[openEHR-EHR-CLUSTER.device.v1] An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.">referenceMaterial 0..1 Cluster Reference material #xD; deviceName 1..1 DvText Device name #xD; type 0..1 DvText Type #xD; uniqueDeviceIdentifierUDI 0..1 DvIdentifier Unique device identifier (UDI) #xD; manufacturer 0..1 DvText Manufacturer #xD; Documentation for this format
[openEHR-EHR-COMPOSITION.report-result.v1] Document to communicate information to others about the result of a test or assessment.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
[RM] Temporal category of this Composition, persistent / episodic or event.
[RM] The person primarily responsible for the content of the Composition (but not necessarily its committal into the EHR system). This is the identifier which should appear on the screen. It may or may not be the person who entered the data. When it is the patient, the special self instance of `PARTY_SELF` will be used.
[RM] `COMPOSITION.context` - Documents the context information of a healthcare event involving the subject of care and the health system. The context information recorded here are independent of the attributes recorded in the version audit, which document the system interaction context, i.e. the context of a user interacting with the health record system. Healthcare events include patient contacts, and any other business activity, such as pathology investigations which take place on behalf of the patient.
participations.exists() implies participations.empty().not()
location.exists() implies location.empty().not()
Start time of the clinical session or other kind of event during which a provider performs a service of any kind for the patient.
Optional end time of the clinical session.
The actual location where the session occurred, e.
The actual location where the session occurred, e.g. 'microbiology lab 2', 'home', 'ward A3' and so on.
[RM] The setting in which the clinical session took place. Coded using the openEHR Terminology, setting group.
Other optional context which will be archetyped.
The health care facility under whose care the event took place.
The health care facility under whose care the event took place. This is the most specific workgroup or delivery unit within a care delivery enterprise that has an official identifier in the health system, and can be used to ensure medico-legal accountability.
Parties involved in the healthcare event.
Parties involved in the healthcare event. These would normally include the physician(s) and often the patient (but not the latter if the clinical session is a pathology test for example).
[RM] COMPOSITION.context.start_time - Start time of the clinical session or other kind of event during which a provider performs a service of any kind for the patient.
[at0002] Identification information about the report.
[openEHR-EHR-CLUSTER.person.v1] An individual human being.
links.exists() implies links.empty().not()
Archetyped valid must satisfy exclusive conditions
is_archetype_root() xor archetype_details .empty()
Archetype node id valid must not be empty
[at0001] The unstructured name for the individual.
Design-time archetype identifier of this node taken from its generating archetype; used to build archetype paths.
Design-time archetype identifier of this node taken from its generating archetype; used to build archetype paths. Always in the form of an at-code, e.g. `at0005`. This value enables a 'standardised' name for this node to be generated, by referring to the generating archetype local terminology. At an archetype root point, the value of this attribute is always the stringified form of the `_archetype_id_` found in the `_archetype_details_` object.
Optional globally unique object identifier for root points of archetyped structures.
Links to other archetyped structures (data whose root object inherits from `ARCHETYPED`, such as `ENTRY`, `SECTION` and so on).
Links to other archetyped structures (data whose root object inherits from `ARCHETYPED`, such as `ENTRY`, `SECTION` and so on). Links may be to structures in other compositions.
Details of archetyping used on this node.
Audit trail from non-openEHR system of original commit of information forming the content of this node, or from a conversion gateway which has synthesised this node.
Ordered list of items - `CLUSTER` or `ELEMENT` objects - under this `CLUSTER`.
[at0003] Identifier associated with the individual.
[openEHR-EHR-CLUSTER.organisation.v1] An entity comprising one or more people and having a particular purpose.
[at0001] The unstructured name or label for the organisation.
[at0003] Identifier associated with the organisation.
[at0019] Additional narrative about the organisation not captured in other fields.
[openEHR-EHR-CLUSTER.xds_metadata.v0] Additional composition metadata aligned with IHE-XDS which is not already available from the Reference Model COMPOSITION class.
Runtime name of this fragment, used to build runtime paths.
Runtime name of this fragment, used to build runtime paths. This is the term provided via a clinical application or batch process to name this EHR construct: its retention in the EHR faithfully preserves the original label by which this entry was known to end users.
[at0001] The speciality of the author/composer of the document.
[at0002] A high-level document class code, normally selected from a valueset provided by the IHE-XDS Affinity Domain.
[at0003] The code specifying the precise type of document from the user perspective. Normally selected from a valueset provided by the local IHE-XDS Affinity Domain or national standard.
[at0004] A term specifying the level of confidentiality of the XDS Document.
[at0007] A term defining the healthcare facility type.
[at0009] The code specifying the clinical specialty where the act that resulted in the document was performed.
[at0011] This list of codes represents the main clinical acts.
[at0010] Additional metadata about the document itself, including size, url.
[openEHR-EHR-INSTRUCTION.service_request.v1] Request for a health-related service or activity to be delivered by a clinician, organisation or agency.
Subject validity must satisfy conditional constraints
subject_is_self() implies subject.generating_type = “PARTY_SELF”
Other participations valid must be present
other_participations.exists() implies other_participations.empty().not()
activities.exists() implies activities.empty().not()
Mandatory indicator of the localised language in which this Entry is written.
Mandatory indicator of the localised language in which this Entry is written. Coded from openEHR Code Set languages .
Name of character set in which text values in this Entry are encoded.
Name of character set in which text values in this Entry are encoded. Coded from openEHR Code Set character sets.
Identifier of externally held workflow engine data for this workflow execution, for this subject of care.
Id of human subject of this `ENTRY`, e.g.: * organ donor * foetus * a family member * another clinically relevant person.
Optional identification of provider of the information in this `ENTRY`, which might be: * the patient * a patient agent, e.
Optional identification of provider of the information in this `ENTRY`, which might be: * the patient * a patient agent, e.g. parent, guardian * the clinician * a device or software Generally only used when the recorder needs to make it explicit. Otherwise, Composition composer and other participants are assumed.
Description of the method (i.e. how) the information in this entry was arrived at. For `OBSERVATIONs`, this is a description of the method or instrument used. For `EVALUATIONs`, how the evaluation was arrived at. For `INSTRUCTIONs`, how to execute the Instruction. This may take the form of references to guidelines, including manually followed and executable; knowledge references such as a paper in Medline; clinical reasons within a larger care process.
Optional external identifier of guideline creating this Entry if relevant.
Optional expiry date/time to assist determination of when an Instruction can be assumed to have expired.
Optional expiry date/time to assist determination of when an Instruction can be assumed to have expired. This helps prevent false listing of Instructions as Active when they clearly must have been terminated in some way or other.
Optional workflow engine executable expression of the Instruction.
[at0121] The name of the service/s requested.
[at0062] The specific problem needing attention or the clinical question that requires investigation.
[openEHR-EHR-CLUSTER.specimen.v1] A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
[openEHR-EHR-CLUSTER.anatomical_location.v1] A physical site on or within the human body.
[at0001] Identification of a single physical site either on, or within, the human body.
at0015: The date and time that collection has been ordered to take place or has taken place.
at0010: The local identifier assigned by the requesting clinical system.
at0011: The local identifier assigned to the request by the clinician or organisation receiving the request for service.
[openEHR-EHR-OBSERVATION.laboratory_test_result.v1] The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
The data of this observation, in the form of a history of values which may be of any complexity.
Optional recording of the state of subject of this observation during the observation process, in the form of a separate history of values which may be of any complexity.
Optional recording of the state of subject of this observation during the observation process, in the form of a separate history of values which may be of any complexity. State may also be recorded within the History of the data attribute.
[RM] `OBSERVATION.EVENT.time` - Time of this Observation event. If the width is non-zero, it is the time point of the trailing edge of the event.
[at0005] Name of the laboratory investigation performed on the specimen(s).
[at0041] Information about whether the specimen was adequate for testing.
[at0073] The status of the laboratory test result as a whole.
[at0075] The date and/or time that ‘Overall test status’ was issued.
[at0077] The diagnostic service or discipline that is responsible for the laboratory test result.
[at0100] Description of clinical information available at the time of interpretation of results.
[openEHR-EHR-CLUSTER.laboratory_test_analyte.v1] The result of a laboratory test for a single analyte value.
[at0024] The name of the analyte result.
at0001: The value of the analyte result.
[at0004] Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.
[at0005] The status of the analyte result value.
[at0006] The date and time that the analyte result was issued for the recorded ‘Result status’.
[at0003] Additional narrative about the analyte result, not captured in other fields.
[at0057] Narrative description of the key findings.
[openEHR-EHR-CLUSTER.media_file.v1] A media file that is acquired or used as part of the healthcare process, and associated metadata.
[at0001] Digital representation of the media file.
[at0002] Descriptive name or title for the media file.
at0004: The date/time, partial date or period when the media file was generated or authored.
[at0007] Additional narrative about the media file not captured in other fields.
[at0094] Details about the test request.
[at0062] The local identifier assigned by the requesting clinical system.
[at0063] The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).
[openEHR-EHR-CLUSTER.structured_name.v1] Discrete components of an individual's name.
[at0001] One or more honorific form(s) of address commencing a name.
[at0002] One or more unique name(s) used to identify an individual within a family group.
[at0005] One or more name(s) that an individual has in common with a family group.
[openEHR-EHR-CLUSTER.device.v1] An instrument, apparatus, implant, material or similar, used in the provision of healthcare. In this context, a medical device includes a broad range of devices which act through a variety of physical, mechanical, thermal or similar means but specifically excludes devices which act through medicinal means such as pharmacological, metabolic or immunological methods. The scope is inclusive of disposable devices as well as durable or persisting devices that require tracking, maintenance activities or regular calibration, recognising that each type of device has specific data recording requirements.
[at0001] Identification of the medical device, preferably by a common name, a formal fully descriptive name or, if required, by class or category of device.
[at0003] The category or kind of device.
[at0021] A numeric or alphanumeric string that is associated with this device within a given system.