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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).
In de klinische bouwsteen OverdrachtLabuitslag kwam de naam van de gekoppelde waardenlijst van concept ResultaatStatus niet overeen met de tagged value van het concept.
In de klinische bouwsteen OverdrachtLabuitslag kwam de naam van de gekoppelde waardenlijst van concept ResultaatType niet overeen met de tagged value van het concept.
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.
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.
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.
Voorbeeld in ART Decor van Testcode klopt niet met codesystemen die genoemd zijn
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
Type
Id
Concept
Card.
Definition
DefinitionCode
Reference
NL-CM:13.1.1
LaboratoryTestResult
Root concept of the LaboratoryTestResult information model. This root concept contains all data elements of the LaboratoryTestResult information model.
NL-CM:13.1.2
Specimen
0..1
Container of the Specimen concept. This container contains all data elements of the Specimen concept.
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.
NL-CM:13.1.20
SpecimenNumberExtension
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
NL-CM:13.1.21
ContainerType
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.
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.
In particular in microbiological determinations the subject of the test is an isolate of a certain microorganism rather then a material. This concept provides the ability to capture information about this microorganism.
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.
NL-CM:13.1.24
CollectionPeriod::TimeInterval
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.
Date and time that the material is handed over at the laboratory or specimen collection center. This is the case with material that is collected by the patient himself.
NL-CM:13.1.18
CollectionMethod
0..1
If relevant for the results, the method of obtaining the specimen can be entered as well.
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.
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.
The upper reference limit for the patient of the value measured in the test.
NL-CM:13.1.12
ReferenceRangeLowerLimit
0..1
The lower reference limit for the patient of the value measured with the test.
NL-CM:13.1.14
ResultFlags
0..1
Attention codes indicating whether the result of a quantitative test is above or below certain reference values or interpreting the result otherwise.(Resistent). The values Resistant, Intermediate en Susceptible are used with microbiological test results.
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.
The status of the laboratory test result. If the laboratory test is a 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.
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
HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR
LaboratoryTestResult
SpecimenId
or as spreadsheet 