LaboratoryTestResult-v4.2(2018EN): verschil tussen versies

Uit Zorginformatiebouwstenen
Naar navigatie springen Naar zoeken springen
(Nieuwe pagina aangemaakt met '<!-- Hieronder wordt een transclude page aangeroepen --> {{Versions-2.16.840.1.113883.2.4.3.11.60.40.3.13.1(EN)|1|LaboratoryTestResult-v4.2(2018EN)}} <!-- Tot hie...')
 
Geen bewerkingssamenvatting
 
Regel 231: Regel 231:
==Information Model==
==Information Model==
<BR>
<BR>
<imagemap> Bestand:LaboratoryTestResult-v4.2Model(EN).png | center  
<imagemap> Bestand:LaboratoryTestResult-v4.2Model(2018EN).png | center  
rect 613 76 725 146 [[LaboratoryTestResult-v4.2(2018EN)]]
rect 623 84 735 154 [[LaboratoryTestResult-v4.2(2018EN)]]
rect 157 387 299 437 [[#ResultStatusCodelist]]
rect 167 395 309 445 [[#ResultStatusCodelist]]
rect 157 88 299 138 [[#PanelOrBatteryCodelist]]
rect 167 96 309 146 [[#PanelOrBatteryCodelist]]
rect 616 177 728 247 [[#12848]]
rect 626 185 738 255 [[#12848]]
rect 322 307 434 377 [[#12891]]
rect 332 315 444 385 [[#12891]]
rect 601 388 741 438 [[#ResultTypeCodelist]]
rect 611 396 751 446 [[#ResultTypeCodelist]]
rect 391 171 509 241 [[#12851]]
rect 401 179 519 249 [[#12851]]
rect 449 307 561 377 [[#12870]]
rect 459 315 571 385 [[#12870]]
rect 172 173 284 243 [[#12847]]
rect 182 181 294 251 [[#12847]]
rect 615 278 727 348 [[#12844]]
rect 625 286 737 356 [[#12844]]
rect 172 278 284 348 [[#12846]]
rect 182 286 294 356 [[#12846]]
rect 311 35 450 105 [[HealthProfessional-v3.2(2018EN)]]
rect 321 43 460 113 [[HealthProfessional-v3.2(2018EN)]]
rect 462 35 601 105 [[HealthcareProvider-v3.2(2018EN)]]
rect 472 43 611 113 [[HealthcareProvider-v3.2(2018EN)]]
desc none
desc none
</imagemap>
</imagemap>
<imagemap> Bestand:LaboratoriumTest-v4.2Model(EN).png | center  
<imagemap> Bestand:LaboratoriumTest-v4.2Model(2018EN).png | center  
rect 177 35 332 85 [[#TestResultStatusCodelist]]
rect 187 43 342 93 [[#TestResultStatusCodelist]]
rect 210 124 300 194 [[#12859]]
rect 220 132 310 202 [[#12859]]
rect 596 121 769 171 [[#InterpretationMethodCodelist]]
rect 606 129 779 179 [[#InterpretationMethodCodelist]]
rect 457 122 566 192 [[#12869]]
rect 467 130 576 200 [[#12869]]
rect 337 122 438 192 [[#12874]]
rect 347 130 448 200 [[#12874]]
rect 32 335 187 385 [[#TestMethodCodelist]]
rect 42 343 197 393 [[#TestMethodCodelist]]
rect 32 251 187 301 [[#TestNameCodelist]]
rect 42 259 197 309 [[#TestNameCodelist]]
rect 312 528 482 578 [[#ResultFlagsCodelist]]
rect 322 536 492 586 [[#ResultFlagsCodelist]]
rect 500 329 616 399 [[#12872]]
rect 510 337 626 407 [[#12872]]
rect 347 431 447 501 [[#12866]]
rect 357 439 457 509 [[#12866]]
rect 353 233 443 303 [[#12870]]
rect 363 241 453 311 [[#12870]]
rect 500 235 616 305 [[#12865]]
rect 510 243 626 313 [[#12865]]
rect 216 332 302 402 [[#12857]]
rect 226 340 312 410 [[#12857]]
rect 213 238 299 308 [[#12861]]
rect 223 246 309 316 [[#12861]]
rect 500 432 616 502 [[#12863]]
rect 510 440 626 510 [[#12863]]
rect 213 431 299 501 [[#12875]]
rect 223 439 309 509 [[#12875]]
desc none
desc none
</imagemap>
</imagemap>
<imagemap> Bestand:Monster-v4.2Model(EN).png | center  
<imagemap> Bestand:Monster-v4.2Model(2018EN).png | center  
rect 259 603 413 653 [[#MicroorganismCodelist]]
rect 269 611 423 661 [[#MicroorganismCodelist]]
rect 97 600 238 650 [[#ContainerTypeCodelist]]
rect 107 608 248 658 [[#ContainerTypeCodelist]]
rect 704 78 916 128 [[#SpecimenAnatomicalLocationCodelist]]
rect 714 86 926 136 [[#SpecimenAnatomicalLocationCodelist]]
rect 704 166 828 216 [[#LateralityCodelist]]
rect 714 174 838 224 [[#LateralityCodelist]]
rect 704 254 828 304 [[#MorphologyCodelist]]
rect 714 262 838 312 [[#MorphologyCodelist]]
rect 281 69 391 139 [[#12882]]
rect 291 77 401 147 [[#12882]]
rect 551 155 661 225 [[#12884]]
rect 561 163 671 233 [[#12884]]
rect 551 329 661 399 [[#12880]]
rect 561 337 671 407 [[#12880]]
rect 146 287 256 357 [[#12879]]
rect 156 295 266 365 [[#12879]]
rect 146 505 256 575 [[#12885]]
rect 156 513 266 583 [[#12885]]
rect 146 396 256 466 [[#12894]]
rect 156 404 266 474 [[#12894]]
rect 281 505 391 575 [[#12876]]
rect 291 513 401 583 [[#12876]]
rect 416 69 526 139 [[#12886]]
rect 426 77 536 147 [[#12886]]
rect 549 69 659 139 [[#12892]]
rect 559 77 669 147 [[#12892]]
rect 555 244 665 314 [[#12889]]
rect 565 252 675 322 [[#12889]]
rect 426 603 576 653 [[#SpecimenMaterialCodelist]]
rect 436 611 586 661 [[#SpecimenMaterialCodelist]]
rect 704 427 871 477 [[#CollectionMethodCodelist]]
rect 714 435 881 485 [[#CollectionMethodCodelist]]
rect 341 286 431 356 [[#12891]]
rect 351 294 441 364 [[#12891]]
rect 551 417 661 487 [[#12887]]
rect 561 425 671 495 [[#12887]]
rect 417 504 527 574 [[#12896]]
rect 427 512 537 582 [[#12896]]
rect 146 178 256 248 [[#12898]]
rect 156 186 266 256 [[#12898]]
rect 551 504 661 574 [[#12881]]
rect 561 512 671 582 [[#12881]]
rect 146 69 256 139 [[#12883]]
rect 156 77 266 147 [[#12883]]
desc none
desc none
</imagemap>
</imagemap>
Regel 879: Regel 879:
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|SNOMED CT: < [https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=71388002 71388002]<noWiki>|</noWiki><span title = "Verrichting" >Procedure</span><noWiki>|</noWiki>
|SNOMED CT: <[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=71388002 71388002]<noWiki>|</noWiki><span title = "Verrichting">Procedure</span><noWiki>|</noWiki>
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 894: Regel 894:
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|SNOMED CT: < [https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=434711009 434711009]<noWiki>|</noWiki>Specimen container<noWiki>|</noWiki>
|SNOMED CT: <[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=434711009 434711009]<noWiki>|</noWiki>Specimen container<noWiki>|</noWiki>
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 930: Regel 930:
|Description<!--vsDescription-->
|Description<!--vsDescription-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Links" >Left</span>
|<span title = "Links">Left</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=7771000 7771000]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=7771000 7771000]
|SNOMED CT
|SNOMED CT
Regel 936: Regel 936:
|Links
|Links
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Rechts" >Right</span>
|<span title = "Rechts">Right</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=24028007 24028007]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=24028007 24028007]
|SNOMED CT
|SNOMED CT
Regel 942: Regel 942:
|Rechts
|Rechts
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Bilateraal" >Right and left</span>
|<span title = "Bilateraal">Right and left</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=51440002 51440002]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=51440002 51440002]
|SNOMED CT
|SNOMED CT
Regel 959: Regel 959:
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|SNOMED CT: ^ [https://terminologie.nictiz.nl/terminology/snomed/viewRefset?id=2581000146104 2581000146104]<noWiki>|</noWiki><span title = "Referentieset voor micro-organismen" >Dutch microorganism simple reference set</span><noWiki>|</noWiki>
|SNOMED CT: ^[https://terminologie.nictiz.nl/terminology/snomed/viewRefset?id=2581000146104 2581000146104]<noWiki>|</noWiki><span title = "Referentieset voor micro-organismen">Dutch microorganism simple reference set</span><noWiki>|</noWiki>
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 974: Regel 974:
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|SNOMED CT: < [https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=49755003 49755003]<noWiki>|</noWiki><span title = "Morfologische afwijking" >Morphologically abnormal structure</span><noWiki>|</noWiki>
|SNOMED CT: <[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=49755003 49755003]<noWiki>|</noWiki><span title = "Morfologische afwijking">Morphologically abnormal structure</span><noWiki>|</noWiki>
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 1.092: Regel 1.092:
|Description<!--vsDescription-->
|Description<!--vsDescription-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Hematologisch onderzoek" >Hematology test</span>
|<span title = "Hematologisch onderzoek">Hematology test</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=252275004 252275004]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=252275004 252275004]
|SNOMED CT
|SNOMED CT
Regel 1.098: Regel 1.098:
|Hematologie
|Hematologie
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Serumtest" >Serum chemistry test</span>
|<span title = "Serumtest">Serum chemistry test</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=275711006 275711006]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=275711006 275711006]
|SNOMED CT
|SNOMED CT
Regel 1.110: Regel 1.110:
|Serologie/ immunologie
|Serologie/ immunologie
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Virologisch onderzoek" >Viral studies</span>
|<span title = "Virologisch onderzoek">Viral studies</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=395124008 395124008]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=395124008 395124008]
|SNOMED CT
|SNOMED CT
Regel 1.116: Regel 1.116:
|Virologie
|Virologie
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Toxicologische test" >Toxicology screening test</span>
|<span title = "Toxicologische test">Toxicology screening test</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=314076009 314076009]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=314076009 314076009]
|SNOMED CT
|SNOMED CT
Regel 1.122: Regel 1.122:
|Toxicologie
|Toxicologie
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|<span title = "Microbiologisch onderzoek" >Microbiology procedure</span>
|<span title = "Microbiologisch onderzoek">Microbiology procedure</span>
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=19851009 19851009]
|[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=19851009 19851009]
|SNOMED CT
|SNOMED CT
Regel 1.145: Regel 1.145:
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|SNOMED CT: < [https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=442083009 442083009]<noWiki>|</noWiki><span title = "Anatomische of verworven lichaamsstructuur" >Anatomical or acquired body structure</span><noWiki>|</noWiki>
|SNOMED CT: <[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=442083009 442083009]<noWiki>|</noWiki><span title = "Anatomische of verworven lichaamsstructuur">Anatomical or acquired body structure</span><noWiki>|</noWiki>
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 1.160: Regel 1.160:
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|SNOMED CT: < [https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=105590001 105590001]<noWiki>|</noWiki><span title = "Substantie" >Substance</span><noWiki>|</noWiki>
|SNOMED CT: <[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=105590001 105590001]<noWiki>|</noWiki><span title = "Substantie">Substance</span><noWiki>|</noWiki>
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 1.175: Regel 1.175:
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|Codesystem name<!--vsConceptSystemName-->||Codesystem OID<!--vsConceptSystemOID-->
|-style="vertical-align:top; "
|-style="vertical-align:top; "
|SNOMED CT: < [https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=272394005 272394005]<noWiki>|</noWiki>Technique<noWiki>|</noWiki>
|SNOMED CT: <[https://terminologie.nictiz.nl/art-decor/snomed-ct?conceptId=272394005 272394005]<noWiki>|</noWiki>Technique<noWiki>|</noWiki>
|SNOMED CT
|SNOMED CT
|2.16.840.1.113883.6.96
|2.16.840.1.113883.6.96
Regel 1.247: Regel 1.247:
*[[HealthProfessional-v3.2(2018EN)|HealthProfessional-v3.2]]
*[[HealthProfessional-v3.2(2018EN)|HealthProfessional-v3.2]]
*[[LaboratoryTestResult-v4.2(2018EN)|LaboratoryTestResult-v4.2]]
*[[LaboratoryTestResult-v4.2(2018EN)|LaboratoryTestResult-v4.2]]
====This inforation model is used in<!--ftReferredBy-->====
====This information model is used in<!--ftReferredBy-->====
*[[LaboratoryTestResult-v4.2(2018EN)|LaboratoryTestResult-v4.2]]
*[[LaboratoryTestResult-v4.2(2018EN)|LaboratoryTestResult-v4.2]]
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
==Technical specifications in HL7v3 CDA and HL7 FHIR<!--ftHeader-->==
Regel 1.266: Regel 1.266:
</ul>
</ul>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
Conditions for use are located on the mainpage<!--ftConditions--> [[Bestand:list2.png|link=HCIM_Mainpage<!--wikiMainpage-->]]<BR>
This page is generated on 01/11/2018 17:35:50 with ZibExtraction v. 2.0.6879.31307<!--ftDate--> <BR>
This page is generated on 23/12/2018 01:18:08 with ZibExtraction v. 3.0.6929.24609<!--ftDate--> <BR>
-----
-----
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2018(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2018(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>
<div style="text-align: right; direction: ltr; margin-left: 1em;" >[[Bestand: Back 16.png| link= HCIM_Release<!--wikiReleasePage-->_2018(EN)]] [[HCIM_Release<!--wikiReleasePage-->_2018(EN) |Back to HCIM list<!--hdBackToMainPage--> ]]</div>

Huidige versie van 24 dec 2018 om 11:57


Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.zorg.LaboratoryTestResult NL.png
Version: 4.2
HCIM Status:Final
Release: 2018
Release status: Prepublished
Release date: 01-10-2018


Back 16.png Back to HCIM list

Metadata

DCM::CoderList Kerngroep Registratie aan de Bron
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::CreationDate 7-6-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name PM
DCM::EndorsingAuthority.Telecom
DCM::Id 2.16.840.1.113883.2.4.3.11.60.40.3.13.1
DCM::KeywordList laboratorium uitslag, lab, laboratorium bepaling
DCM::LifecycleStatus Final
DCM::ModelerList Kerngroep Registratie aan de Bron
DCM::Name nl.zorg.LaboratoriumUitslag
DCM::PublicationDate 01-10-2018
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 31-12-2017
DCM::Superseeds nl.zorg.LaboratoriumUitslag-v4.1
DCM::Version 4.2
HCIM::PublicationLanguage EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (15-02-2013)

Publicatieversie 1.1 (01-07-2013)

Publicatieversie 1.2 (01-04-2015)

ZIB-238 In de klinische bouwsteen OverdrachtLabUitslag de tagged value DCM::ValueSet LOINC - eLab valueset van concept TestNaam opsplitsen.
ZIB-239 In de klinische bouwsteen OverdrachtLabUitslag de tagged value DCM::ValueSet SNOMED - eLab valueset van concept Testmethode opsplitsen.
ZIB-240 In de klinische bouwsteen OverdrachtLabUitslag kwam de tagged value DCM::ValueSet van concept LaboratoriumTest niet overeen met de naam van de gekoppelde waardenlijst ResultNormalcyStatus Valueset (HL7).
ZIB-241 In de klinische bouwsteen OverdrachtLabUitslag de tagged value DCM::ValueSet LOINC - eLab valueset van concept Onderzoek opsplitsen.
ZIB-242 In de klinische bouwsteen OverdrachtLabuitslag kwam de naam van de gekoppelde waardenlijst van concept ResultaatStatus niet overeen met de tagged value van het concept.
ZIB-243 In de klinische bouwsteen OverdrachtLabuitslag kwam de naam van de gekoppelde waardenlijst van concept ResultaatType niet overeen met de tagged value van het concept.
ZIB-244 Tagged values van concept Onderzoek van OverdrachtLabUitslag aangepast, door tagged value DCM:ValueSet e-lab een codelijst naam te geven incl. in tagged value notes verwijzing naar extern codesystem.
ZIB-245 Tagged values van concept Testmethode van OverdrachtLabUitslag aangepast, door tagged value DCM:ValueSet e-lab een codelijst naam te geven incl. in tagged value notes verwijzing naar extern codesystem.
ZIB-246 Tagged values van concept TestNaam van OverdrachtLabUitslag aangepast, door tagged value DCM:ValueSet e-lab een codelijst naam te geven incl. in tagged value notes verwijzing naar extern codesystem.
ZIB-353 Tagged values DCM::CodeSystem aanpassen naar DCM::ValueSet incl. gekoppelde codelijst.
ZIB-361 Naamgeving concept Opmerking aangepast
ZIB-367 Opschonen ResultaatVlaggenCodelijst
ZIB-370 ResultaatStatusCodelijst en TekstUitslagCodelijst codes aanpassen

Incl. algemene wijzigingsverzoeken:

ZIB-94 Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
ZIB-154 Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
ZIB-200 Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
ZIB-201 Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
ZIB-309 EOI aangepast
ZIB-324 Codelijsten Name en Description beginnen met een Hoofdletter
ZIB-326 Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015

Publicatieversie 1.2.1 (22-05-2015)

ZIB-392 De ResultaatTypeCodelijst heeft geen "OID: " aanduiding in de onderliggende codelijst.

Publicatieversie 1.2.2 (16-07-2015)

ZIB-420 Vervallen SNOMED CT code in ResultaatTypeCodelijst

Publicatieversie 3.0 (01-05-2016)

ZIB-423 Verkeerd bron-codestelsel gekoppeld aan de 'TestStatusCodelijst'.
ZIB-453 Wijziging naamgeving ZIB's en logo's door andere opzet van beheer

Publicatieversie 4.0 (04-09-2017)

ZIB-479 Monster herkomst ontbreekt
ZIB-549 De Engelse naam van de bouwsteen en het rootconcept zijn niet correct
ZIB-564 Aanpassing/harmonisatie Engelse conceptnamen
ZIB-576 Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen.
ZIB-481 Ambiguïteit in interpretatie van ResultaatStatus
ZIB-577 Toevoegen SNOMED CT concept in ResultaatTypeCodelijst

Publicatieversie 4.1 (31-12-2017)

ZIB-609 Biopsie niet in AfnameprocedureCodelijst
ZIB-611 cardinaliteit ResultaatType
ZIB-621 Aanpassingen naar aanleiding van overleg met NHG
ZIB-645 Diverse terminologiekoppelingen lijken niet te kloppen
ZIB-646 Aanpassing SNOMED codes

Publicatieversie 4.2 (01-10-2018)

ZIB-649 Toevoegen data-element UitgevoerdDoor
ZIB-676 Typefout in "CollectioMethodCodelist"

Concept

A laboratory result describes the result of a laboratory analysis.
These are specimen-oriented tests as performed in laboratories such as Clinical Chemistry, Serology, Microbiology, etc.
In addition to the results of tests with a singular result, this concept can also contain the results of more complex tests with multiple results or a ‘panel’.

Purpose

Laboratory tests are done for the purpose of diagnosing and preventing disease and follow-up on the effects of treatment.

Evidence Base

There are two information models for recording laboratory test results: TextResult and LaboratoryTestResult.

In the case of laboratory test results, it is difficult to clearly indicate exactly when to use this information model and when to use the TextResult information model.
In general, laboratory tests resulting in a value (7.1 mmol/L), ordinal number (++ from series to ++++) or a quantitative result (Low) are recorded using this information model. The TextResult information model is better suited for textual results that are more descriptive in nature and which are longer than just a few words. Both types of tests occur in almost all laboratories.
The applicability of the aforementioned information models is not determined by the kind of lab but by the kind of result.

Information Model


LaboratoryTestResult-v4.2(2018EN)#ResultStatusCodelist#PanelOrBatteryCodelist#12848#12891#ResultTypeCodelist#12851#12870#12847#12844#12846HealthProfessional-v3.2(2018EN)HealthcareProvider-v3.2(2018EN)LaboratoryTestResult-v4.2Model(2018EN).png
#TestResultStatusCodelist#12859#InterpretationMethodCodelist#12869#12874#TestMethodCodelist#TestNameCodelist#ResultFlagsCodelist#12872#12866#12870#12865#12857#12861#12863#12875LaboratoriumTest-v4.2Model(2018EN).png
#MicroorganismCodelist#ContainerTypeCodelist#SpecimenAnatomicalLocationCodelist#LateralityCodelist#MorphologyCodelist#12882#12884#12880#12879#12885#12894#12876#12886#12892#12889#SpecimenMaterialCodelist#CollectionMethodCodelist#12891#12887#12896#12898#12881#12883Monster-v4.2Model(2018EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:13.1.1 Arrowdown.pngLaboratoryTestResult Root concept of the LaboratoryTestResult information model. This root concept contains all data elements of the LaboratoryTestResult information model.
Folder.png NL-CM:13.1.2 Arrowdown.pngSpecimen 0..1 Container of the Specimen concept. This container contains all data elements of the Specimen concept.
123038009 Specimen
II.png NL-CM:13.1.15 Arrowright.pngSpecimenId 0..* Identification number of the material obtained, as a reference for inquiries to the source organization. In a transmural setting, this number will consist of a specimen number including the identification of the issuing organization, to be unique outside of the borders of an organization.
INT.png NL-CM:13.1.20 Arrowright.pngSpecimenNumberExtension 0..1 The specimen number extension is used when the collected material is distributed from the original tube or container across multiple tubes. In combination with the specimen Id the extension yield a unique identification of the tube or container
CD.png NL-CM:13.1.21 Arrowright.pngContainerType 0..1 Container type describes the envelope in which the material is collected or sent. Examples include blood tubes, transport container, possibly including culture medium.
List2.png ContainerTypeCodelist
CD.png NL-CM:13.1.16 Arrowright.pngSpecimenMaterial 0..1 SpecimenMaterial describes the material obtained. If the LOINC test code also implicitly describes a material, this element may not conflict with the description. If desired, this component can provide a more detailed description of the material: LOINC codes only contain the materials at a main level.

This is in line with the agreements made in the IHE/Nictiz program e-Lab.

If the test is carried out on derived material (such as plasma), this element will still contain the material drawn (in this case, blood). In this case, the LOINC code will generally refer to plasma.

370133003 Specimen substance
List2.png SpecimenMaterialCodelist
CD.png NL-CM:13.1.22 Arrowright.pngMicroorganism 0..1 In particular in microbiological determinations the subject of the test is an isolate of certain microorganism rather then a material. This concept provides the ability to capture information about this microorganism.
List2.png MicroorganismCodelist
PQ.png NL-CM:13.1.23 Arrowright.pngCollectedVolume 0..1 Total volume of the collected material. If it is necessary to determine the absolute amount of a particular substance in the collected material, the volume thereof must be given.
TS.png NL-CM:13.1.24 Arrowright.pngCollectionPeriod 0..1 If the material has not been collected at a single point in time but over a certain period, this period can be captured in this concept. An example is 24 hour urine.
TS.png NL-CM:13.1.17 Arrowright.pngCollectionDateTime 0..1 Time at which the material was collected.
399445004 Specimen collection date
TS.png NL-CM:13.1.25 Arrowright.pngReceivedDateTime 0..1 Date and time that the material is handed over at the laboratory or specimen collection center. This is the issue with material that is collected by the patient himself.
CD.png NL-CM:13.1.18 Arrowright.pngCollectionMethod 0..1 If relevant for the results, the method of obtaining the specimen can be entered as well.
118171006 Specimen procedure
List2.png CollectionMethodCodelist
CD.png NL-CM:13.1.26 Arrowright.pngAnatomicalLocation 0..1 Anatomic location where the material is collected, e.g. elbow
405814001 Procedure site - Indirect
List2.png SpecimenAnatomicalLocationCodelist
CD.png NL-CM:13.1.27 Arrowright.pngLaterality 0..1 Laterality adds information about body side to the anatomic location, e.g. left
272741003 Laterality
List2.png LateralityCodelist
CD.png NL-CM:13.1.28 Arrowright.pngMorphology 0..1 Morphology describes morphological abnormalities of the anatomical location where the material is taken, for example wound, ulcer.
118168003 Specimen source morphology
List2.png MorphologyCodelist
ST.png NL-CM:13.1.29 Arrowright.pngSpecimenSource 0..1 If the material is not collected directly from the patient but comes from a patient-related object, e.g. a cathetertip, this source of material can be recorded here.
127454002 Device specimen
ST.png NL-CM:13.1.19 Arrowright.pngComment 0..1 Comments on administering the test, such as drawing material after a (glucose) stimulus or taking medicine.
48767-8 Annotation comment [Interpretation] Narrative
Folder.png NL-CM:13.1.3 Arrowdown.pngLaboratoryTest 0..* Container of the LaboratoryTest concept. This container contains all data elements of the LaboratoryTest concept.
CD.png NL-CM:13.1.8 Arrowright.pngTestCode 1 The name and code of the executed test.
List2.png TestNameCodelist
CD.png NL-CM:13.1.9 Arrowright.pngTestMethod 0..1 The test method used to obtain the result.
246501002 Technique
List2.png TestMethodCodelist
TS.png NL-CM:13.1.13 Arrowright.pngTestDateTime 0..1 The date and if possible the time at which the test was carried out.
ANY.png NL-CM:13.1.10 Arrowright.pngTestResult 0..1 The test result. Depending on the type of test, the result will consist of a value with a unit or a coded value (ordinal or nominal).
CD.png NL-CM:13.1.31 Arrowright.pngTestResultStatus 0..1 The status of the test result of this test. If the laboratory test is an panel/cluster, the overall status is given in the status of the panel/cluster.
List2.png TestResultStatusCodelist
ANY.png NL-CM:13.1.11 Arrowright.pngReferenceRangeUpperLimit 0..1 The upper reference limit for the patient of the value measured in the test.
ANY.png NL-CM:13.1.12 Arrowright.pngReferenceRangeLowerLimit 0..1 The lower reference limit for the patient of the value measured with the test.
CD.png NL-CM:13.1.30 Arrowright.pngInterpretationMethod 0..1 The method used to determine interpretation flags. An example of this is EUCAST, for determining clinical breakpoints in microbiological susceptibility tests
List2.png InterpretationMethodCodelist
CD.png NL-CM:13.1.14 Arrowright.pngResultFlags 0..* Attention codes indicating whether the result is above or below certain reference values or interpreting the result otherwise.(Resistent)
363713009 Has interpretation
List2.png ResultFlagsCodelist
ST.png NL-CM:13.1.32 Arrowright.pngResultInterpretation 0..1 Comment of the laboratory specialist regarding the interpretation of the results
441742003 Evaluation finding
CD.png NL-CM:13.1.4 Arrowright.pngPanelOrBattery 0..1 For laboratory tests comprising multiple subtests and often requested together as a whole, this concept contains the name of the compound request (often indicated as a ‘panel’, ‘battery’ or ‘cluster’). Examples include: blood gases and EBV serology.
List2.png PanelOrBatteryCodelist
CD.png NL-CM:13.1.6 Arrowright.pngResultStatus 0..1 The status of the laboratory test result .If the laboratory test is an panel/cluster, this status reflects the status of the whole panel/cluster. If the status item per subtest is used too, this status must be in accordance with these status values.
List2.png ResultStatusCodelist
ST.png NL-CM:13.1.5 Arrowright.pngComment 0..1 Comments, such as a textual interpretation or advice accompanying the result, for example.
48767-8 Annotation comment [Interpretation] Narrative
CD.png NL-CM:13.1.7 Arrowright.pngResultType 0..1 The type of result defines the laboratory specialty under which the test is categorized.
List2.png ResultTypeCodelist
Verwijzing.png NL-CM:13.1.33 Arrowright.pngRelatedResult::LaboratoryTestResult 0..* Reference to related tests, e.g. paired tests or sequential tests like gram staining and microbiological cultures
Block.png LaboratoryTestResult
Verwijzing.png NL-CM:13.1.34 Arrowright.pngRequester::HealthProfessional 0..1 The healthcare provider and/or organization where or by whom the LaboratoryTestResult was requested.
Block.png HealthProfessional
Verwijzing.png NL-CM:13.1.35 Arrowright.pngPerformer::HealthcareProvider 0..1 The healthcare provider and/or organization where or by whom the LaboratoryTestResult was performed.
Block.png HealthcareProvider

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page List2.png

Example Instances

Only available in Dutch

LaboratoriumUitslag
Resultaat
Type
Resultaat
Status
Monster LaboratoriumTest
Monster
materiaal
Afname
DatumTijd
TestCode Test
DatumTijd
TestUitslag Referentie
Ondergrens
Referentie
Bovengrens
Interpretatie
Vlaggen
Klinische chemie Definitief Bloed 12-06-2012 09:00 Natrium 12-06-2012 13:15 138 mmol/l 136 mmol/l 146 mmol/l
LaboratoriumUitslag
Resultaat
Type
Resultaat
Status
Monster LaboratoriumTest
Monster
materiaal
Afname
DatumTijd
TestCode Test
DatumTijd
TestUitslag Referentie
Ondergrens
Referentie
Bovengrens
Interpretatie
Vlaggen
Klinische chemie Definitief Bloed 23-05-2012 08:08 Chloride 23-05-2012 12:00 109 mmol/l 99 mmol/l 108 mmol/l Boven referentie-
waarde
LaboratoriumUitslag
Resultaat
Type
Resultaat
Status
Monster LaboratoriumTest
Monster
materiaal
Afname
DatumTijd
TestCode Test
DatumTijd
TestUitslag Referentie
Ondergrens
Referentie
Bovengrens
Interpretatie
Vlaggen
Virologie Definitief Bloed 16-01-2012 08:00 Hepatitis A IgM 16-01-2012 10:12 Negatief

References

1. Nederlandse Vereniging voor Medische Microbiologie (2010) ELab en EvT. [Online] Beschikbaar op: http://www.nvmm.nl/ict/vereniging/werkgroepen_commissies/elab-en-evt [Geraadpleegd: 23 juli 2014].

Valuesets

CollectionMethodCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.2 Binding: Extensible
Conceptname Codesystem name Codesystem OID
SNOMED CT: <71388002|Procedure| SNOMED CT 2.16.840.1.113883.6.96

ContainerTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.9 Binding: Extensible
Conceptname Codesystem name Codesystem OID
SNOMED CT: <434711009|Specimen container| SNOMED CT 2.16.840.1.113883.6.96

InterpretationMethodCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.14 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
EUCAST tbd SNOMED CT 2.16.840.1.113883.6.96 EUCAST

LateralityCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.12 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Left 7771000 SNOMED CT 2.16.840.1.113883.6.96 Links
Right 24028007 SNOMED CT 2.16.840.1.113883.6.96 Rechts
Right and left 51440002 SNOMED CT 2.16.840.1.113883.6.96 Rechts en links

MicroorganismCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.10 Binding: Extensible
Conceptname Codesystem name Codesystem OID
SNOMED CT: ^2581000146104|Dutch microorganism simple reference set| SNOMED CT 2.16.840.1.113883.6.96

MorphologyCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.13 Binding: Extensible
Conceptname Codesystem name Codesystem OID
SNOMED CT: <49755003|Morphologically abnormal structure| SNOMED CT 2.16.840.1.113883.6.96

PanelOrBatteryCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.5 Binding: Extensible
Conceptname Codesystem name Codesystem OID
Alle waarden LOINC 2.16.840.1.113883.6.1

ResultFlagsCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.7 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Above reference range 281302008 SNOMED CT 2.16.840.1.113883.6.96 Boven referentiewaarde
Below reference range 281300000 SNOMED CT 2.16.840.1.113883.6.96 Onder referentiewaarde
Intermediate 11896004 SNOMED CT 2.16.840.1.113883.6.96 Intermediair
Resistant 30714006 SNOMED CT 2.16.840.1.113883.6.96 Resistent
Susceptible 131196009 SNOMED CT 2.16.840.1.113883.6.96 Sensitief

ResultStatusCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.8 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Pending pending ResultaatStatus 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 Uitslag volgt
Preliminary preliminary ResultaatStatus 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 Voorlopig
Final final ResultaatStatus 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 Definitief
Appended appended ResultaatStatus 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 Aanvullend
Corrected corrected ResultaatStatus 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 Gecorrigeerd

ResultTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.1 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Hematology test 252275004 SNOMED CT 2.16.840.1.113883.6.96 Hematologie
Serum chemistry test 275711006 SNOMED CT 2.16.840.1.113883.6.96 Klinische chemie
Serologic test 68793005 SNOMED CT 2.16.840.1.113883.6.96 Serologie/ immunologie
Viral studies 395124008 SNOMED CT 2.16.840.1.113883.6.96 Virologie
Toxicology screening test 314076009 SNOMED CT 2.16.840.1.113883.6.96 Toxicologie
Microbiology procedure 19851009 SNOMED CT 2.16.840.1.113883.6.96 Microbiologie
Molecular genetic test 405825005 SNOMED CT 2.16.840.1.113883.6.96 Moleculaire genetica

SpecimenAnatomicalLocationCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.11 Binding: Extensible
Conceptname Codesystem name Codesystem OID
SNOMED CT: <442083009|Anatomical or acquired body structure| SNOMED CT 2.16.840.1.113883.6.96

SpecimenMaterialCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.6 Binding: Extensible
Conceptname Codesystem name Codesystem OID
SNOMED CT: <105590001|Substance| SNOMED CT 2.16.840.1.113883.6.96

TestMethodCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.4 Binding: Extensible
Conceptname Codesystem name Codesystem OID
SNOMED CT: <272394005|Technique| SNOMED CT 2.16.840.1.113883.6.96

TestNameCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.3 Binding: Extensible
Conceptname Codesystem name Codesystem OID
Alle waarden LOINC 2.16.840.1.113883.6.1

TestResultStatusCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.15 Binding: Extensible
Conceptname Conceptcode Codesystem name Codesystem OID Description
Pending pending ResultaatStatus 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 Uitslag volgt
Preliminary preliminary ResultaatStatus 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 Voorlopig
Final final ResultaatStatus 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 Definitief
Appended appended ResultaatStatus 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 Aanvullend
Corrected corrected ResultaatStatus 2.16.840.1.113883.2.4.3.11.60.40.4.16.1 Gecorrigeerd

This information model in other releases

Information model references

This information model refers to

This information model is used in

Technical specifications in HL7v3 CDA and HL7 FHIR

To exchange information based on health and care information models, additional, more technical specifications are required.
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:

  • HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment Artdecor.jpg
  • HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR Fhir.png

Downloads

This information model is also available as pdf file PDF.png or as spreadsheet Xlsx.png

About this information

The information in this wikipage is based on Prerelease 2018 #1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms version: 20180731 [R] (July 2018 Release)
  • LOINC version 2.64

Conditions for use are located on the mainpage List2.png
This page is generated on 23/12/2018 01:18:08 with ZibExtraction v. 3.0.6929.24609


Back 16.png Back to HCIM list