EHDS refined base model for Laboratory result report

Common header for all patient-related data

Patient/subject information

Unique identifier of the document

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of the issuing the document/resource by its author.

Date and time of the last update to the document/information

Status of the resource

Reason for the current status of the resource.

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

BCP 47

Business version of the resource.

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

Identifies the type of document at hand, e.g. Discharge report.

LOINC

Document title, such as Discharge Report, Laboratory Result Report, etc.

The status of the Discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

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

Document legal authentication

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Categorization 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 betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

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.

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Related documents and information sources

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

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

Common header for all patient-related data

Patient/subject information

Unique identifier of the document

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of the issuing the document/resource by its author.

Date and time of the last update to the document/information

Status of the resource

Reason for the current status of the resource.

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

BCP 47

Business version of the resource.

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

Identifies the type of document at hand, e.g. Discharge report.

LOINC

Document title, such as Discharge Report, Laboratory Result Report, etc.

The status of the Discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

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

Document legal authentication

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Categorization 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 betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

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.

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Related documents and information sources

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