Release 5 Draft Ballot

This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions

Orders and Observations Work GroupMaturity Level: 2 Trial UseSecurity Category: Patient Compartments: Device, Patient, Practitioner

Detailed Descriptions for the elements in the Specimen resource.

Specimen
Element IdSpecimen
Definition

A sample to be used for analysis.

Cardinality0..*
TypeDomainResource
Summaryfalse
Specimen.identifier
Element IdSpecimen.identifier
Definition

Id for specimen.

NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Summarytrue
Specimen.accessionIdentifier
Element IdSpecimen.accessionIdentifier
Definition

The identifier assigned by the lab when accessioning specimen(s). This is not necessarily the same as the specimen identifier, depending on local lab procedures.

Cardinality0..1
TypeIdentifier
Summarytrue
Specimen.status
Element IdSpecimen.status
Definition

The availability of the specimen.

Cardinality0..1
Terminology BindingSpecimenStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summarytrue
Comments

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

Specimen.type
Element IdSpecimen.type
Definition

The kind of material that forms the specimen.

Cardinality0..1
Terminology Bindinghl7VS-specimenType (Example)
TypeCodeableConcept
Summarytrue
Comments

The type can change the way that a specimen is handled and drives what kind of analyses can properly be performed on the specimen. It is frequently used in diagnostic work flow decision making systems.

Specimen.subject
Element IdSpecimen.subject
Definition

Where the specimen came from. This may be from patient(s), from a location (e.g., the source of an environmental sample), or a sampling of a substance, a biologically-derived product, or a device.

Cardinality0..1
TypeReference(Patient | Group | Device | BiologicallyDerivedProduct | Substance | Location)
PatternsReference(Patient,Group,Device,BiologicallyDerivedProduct,Substance,Location): No common pattern
Requirements

Must know the subject context.

Summarytrue
Specimen.receivedTime
Element IdSpecimen.receivedTime
Definition

Time when specimen is received by the testing laboratory for processing or testing.

Cardinality0..1
TypedateTime
Summarytrue
Specimen.parent
Element IdSpecimen.parent
Definition

Reference to the parent (source) specimen which is used when the specimen was either derived from or a component of another specimen.

Cardinality0..*
TypeReference(Specimen)
Summaryfalse
Comments

The parent specimen could be the source from which the current specimen is derived by some processing step (e.g. an aliquot or isolate or extracted nucleic acids from clinical samples) or one of many specimens that were combined to create a pooled sample.

Specimen.request
Element IdSpecimen.request
Definition

Details concerning a service request that required a specimen to be collected.

Cardinality0..*
TypeReference(ServiceRequest)
Summaryfalse
Comments

The request may be explicit or implied such with a ServiceRequest that requires a blood draw.

Specimen.feature
Element IdSpecimen.feature
Definition

A physical feature or landmark on a specimen, highlighted for context by the collector of the specimen (e.g. surgeon), that identifies the type of feature as well as its meaning (e.g. the red ink indicating the resection margin of the right lobe of the excised prostate tissue or wire loop at radiologically suspected tumor location).

Cardinality0..*
Summaryfalse
Specimen.feature.type
Element IdSpecimen.feature.type
Definition

The landmark or feature being highlighted.

Cardinality1..1
Terminology BindingSNOMED CT Body Structures (Example)
TypeCodeableConcept
Summaryfalse
Specimen.feature.description
Element IdSpecimen.feature.description
Definition

Description of the feature of the specimen.

Cardinality1..1
Typestring
Summaryfalse
Specimen.collection
Element IdSpecimen.collection
Definition

Details concerning the specimen collection.

Cardinality0..1
Summaryfalse
Specimen.collection.collector
Element IdSpecimen.collection.collector
Definition

Person who collected the specimen.

Cardinality0..1
TypeReference(Practitioner | PractitionerRole | Patient | RelatedPerson)
PatternsReference(Practitioner,PractitionerRole,Patient,RelatedPerson): Common patterns = Participant
Summarytrue
Specimen.collection.collected[x]
Element IdSpecimen.collection.collected[x]
Definition

Time when specimen was collected from subject - the physiologically relevant time.

Cardinality0..1
TypedateTime|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue
Specimen.collection.duration
Element IdSpecimen.collection.duration
Definition

The span of time over which the collection of a specimen occurred.

Cardinality0..1
TypeDuration
Summarytrue
Specimen.collection.quantity
Element IdSpecimen.collection.quantity
Definition

The quantity of specimen collected; for instance the volume of a blood sample, or the physical measurement of an anatomic pathology sample.

Cardinality0..1
TypeSimpleQuantity
Summaryfalse
Specimen.collection.method
Element IdSpecimen.collection.method
Definition

A coded value specifying the technique that is used to perform the procedure.

Cardinality0..1
Terminology BindingFHIR Specimen Collection Method (Example)
TypeCodeableConcept
Summaryfalse
Specimen.collection.device
Element IdSpecimen.collection.device
Definition

A coded value specifying the technique that is used to perform the procedure.

Cardinality0..1
Terminology BindingSpecimenCollectionDevice:
TypeCodeableReference(Device)
Summaryfalse
Specimen.collection.procedure
Element IdSpecimen.collection.procedure
Definition

The procedure event during which the specimen was collected (e.g. the surgery leading to the collection of a pathology sample).

Cardinality0..1
TypeReference(Procedure)
Summaryfalse
Specimen.collection.bodySite
Element IdSpecimen.collection.bodySite
Definition

Anatomical location from which the specimen was collected (if subject is a patient). This is the target site. This element is not used for environmental specimens.

Cardinality0..1
Terminology BindingSNOMED CT Body Structures (Example)
TypeCodeableReference(BodyStructure)
Summaryfalse
Comments

Reasons for using BodyStructure reference include: 1.) Need to identify a specific site instance (e.g. a specific mole), 2.) a single pre-coordinated coded concept for the body site does not exist, 3.) a desire to represent bodySite using multiple attributes (e.g. modifiers).

Specimen.collection.fastingStatus[x]
Element IdSpecimen.collection.fastingStatus[x]
Definition

Abstinence or reduction from some or all food, drink, or both, for a period of time prior to sample collection.

Cardinality0..1
Terminology Bindinghl7VS-relevantClincialInformation (Extensible)
TypeCodeableConcept|Duration
[x] NoteSee Choice of Data Types for further information about how to use [x]
Requirements

Many diagnostic tests require fasting to facilitate accurate interpretation.

Summarytrue
Comments

Representing fasting status using this element is preferred to representing it with an observation using a 'pre-coordinated code' such as LOINC 2005-7 (Calcium [Moles/​time] in 2 hour Urine --12 hours fasting), or using a component observation such asObservation.component code` = LOINC 49541-6 (Fasting status - Reported).

Specimen.processing
Element IdSpecimen.processing
Definition

Details concerning processing and processing steps for the specimen.

Cardinality0..*
Summaryfalse
Specimen.processing.description
Element IdSpecimen.processing.description
Definition

Textual description of procedure.

Cardinality0..1
Typestring
Summaryfalse
Specimen.processing.method
Element IdSpecimen.processing.method
Definition

A coded value specifying the method used to process the specimen.

Cardinality0..1
Terminology BindingSpecimenProcessingMethod (Example)
TypeCodeableConcept
Summaryfalse
Specimen.processing.additive
Element IdSpecimen.processing.additive
Definition

Material used in the processing step.

Cardinality0..*
TypeReference(Substance)
Summaryfalse
Specimen.processing.time[x]
Element IdSpecimen.processing.time[x]
Definition

A record of the time or period when the specimen processing occurred. For example the time of sample fixation or the period of time the sample was in formalin.

Cardinality0..1
TypedateTime|Period
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summaryfalse
Specimen.container
Element IdSpecimen.container
Definition

The container holding the specimen. The recursive nature of containers; i.e. blood in tube in tray in rack is not addressed here.

Cardinality0..*
Summaryfalse
Specimen.container.device
Element IdSpecimen.container.device
Definition

The device resource for the the container holding the specimen. If the container is in a holder then the referenced device will point to a parent device.

Cardinality1..1
TypeReference(Device)
Summaryfalse
Specimen.container.location
Element IdSpecimen.container.location
Definition

The location of the container holding the specimen.

Cardinality0..1
TypeReference(Location)
Summaryfalse
Specimen.container.specimenQuantity
Element IdSpecimen.container.specimenQuantity
Definition

The quantity of specimen in the container; may be volume, dimensions, or other appropriate measurements, depending on the specimen type.

Cardinality0..1
TypeSimpleQuantity
Summaryfalse
Specimen.condition
Element IdSpecimen.condition
Definition

A mode or state of being that describes the nature of the specimen.

Cardinality0..*
Terminology Bindinghl7VS-specimenCondition (Extensible)
TypeCodeableConcept
Requirements

The specimen condition can be used to assess its quality or appropriateness for a specific test.

Summarytrue
Comments

Specimen condition is an observation made about the specimen. It's a point-in-time assessment. It can be used to assess its quality or appropriateness for a specific test.

Specimen.note
Element IdSpecimen.note
Definition

To communicate any details or issues about the specimen or during the specimen collection. (for example: broken vial, sent with patient, frozen).

Cardinality0..*
TypeAnnotation
Summaryfalse