LaboratoryTestResult-v6.0(2022EN)

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General information

Name: nl.zorg.LaboratoryTestResult NL.png
Version: 6.0
HCIM Status:Final
Release: 2022
Release status: Prepublished
Release date: 15-10-2023

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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 15-10-2023
DCM::PublicationStatus Prepublished
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 17-07-2023
DCM::Supersedes nl.zorg.LaboratoriumUitslag-v5.1
DCM::Version 6.0
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)

Issue summaries niet beschikbaar
Bevat: ZIB-238, ZIB-239, ZIB-240, ZIB-241, ZIB-242, ZIB-243, ZIB-244, ZIB-245, ZIB-246, ZIB-353, ZIB-361, ZIB-367, ZIB-370.

Incl. algemene wijzigingsverzoeken: ZIB-94, ZIB-154, ZIB-200, ZIB-201, ZIB-309, ZIB-324, ZIB-326.

Publicatieversie 1.2.1 (22-05-2015) Bevat: ZIB-392.

Publicatieversie 1.2.2 (16-07-2015) Bevat: ZIB-420.

Publicatieversie 3.0 (01-05-2016) Bevat: ZIB-423, ZIB-453.

Publicatieversie 4.0 (04-09-2017) Bevat: ZIB-479, ZIB-549, ZIB-564, ZIB-576, ZIB-481, ZIB-577.

Publicatieversie 4.1 (31-12-2017) Bevat: ZIB-609, ZIB-611, ZIB-621, ZIB-645, ZIB-646.

Publicatieversie 4.2 (01-10-2018) Bevat: ZIB-649, ZIB-676.

Publicatieversie 4.3 (26-02-2019) Bevat: ZIB-639, ZIB-703.

Publicatieversie 4.4 (06-07-2019) Bevat: ZIB-669, ZIB-880.

Publicatieversie 4.5 (31-01-2020) Bevat: ZIB-910, ZIB-901, ZIB-902.

Publicatieversie 4.6 (01-09-2020) Bevat: ZIB-1016, ZIB-1148.

Publicatieversie 5.0 (01-12-2021) Bevat: ZIB-1072, ZIB-1269, ZIB-1293, ZIB-1465, ZIB-1551, ZIB-1553.

Publicatieversie 5.1 (10-06-2022) Bevat: ZIB-1292, ZIB-1552, ZIB-1686, ZIB-1698, ZIB-1699.

Publicatieversie 6.0 (15-10-2023) Bevat: ZIB-1584, ZIB-1697,ZIB-1784, ZIB-1845, ZIB-1958, ZIB-1990, ZIB-1974, ZIB-2019.

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-v5.1(2022EN)#ResultStatusCodelist#PanelOrBatteryCodelist#1132#1173#ResultTypeCodelist#1135#1131#1128#1130HealthcareProvider-v3.5(2022EN)#1153LaboratoryTestResult-v6.0Model(2022EN).png
#TestResultStatusCodelist#1142#1157#TestMethodCodelist#TestNameLOINCCodelist#ResultFlagsCodelist#1155#1149#1153#1148#1140#1144#1146#1158#TestCodeNHGCodelist#TestResultCodelistLaboratoriumTest-v6.0Model(2022EN).png
#MicroorganismCodelist#ContainerTypeCodelist#MorphologyCodelist#1165#1162#1161#1167#1174#1159#1168#1171#SpecimenMaterialCodelist#CollectionMethodCodelist#1173#1169#1176#1178#1163#1166AnatomicalLocation-v1.0.2(2022EN)#SpecimenSourceCodelistMonster-v6.0Model(2022EN).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 concept Specimen. This container contains all data elements of the concept Specimen. A completed container is related to a sample from the Snomed Hierarchy.

If the TestCode implicitly also describes a specimen (often the case if coded in LOINC), elements within the concept specimen may not conflict with it. However, if desired, these data can provide a more detailed description.This is in line with the agreements made in the IHE/Nictiz e-Lab programme.

123038009 Specimen
II.png NL-CM:13.1.15 Arrowright.pngSpecimenId 0..1 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.
706046003 Specimen receptacle
List2.png ContainerTypeCodelist
CD.png NL-CM:13.1.16 Arrowright.pngSpecimenMaterial 0..1 SpecimenMaterial describes the base material taken. For example: Plasma, Urine, Saliva etc. This element refers to the Substance hierarchy in Snomed.
370133003 Specimen substance
List2.png SpecimenMaterialCodelist
Verwijzing.png NL-CM:13.1.36 Arrowright.pngAnatomicalLocation 0..1 Anatomical location where the material is collected, <i>e.g. </i>elbow.
405814001 Procedure site - Indirect
Block.png AnatomicalLocation
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 a 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.
PQ.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 Date and 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 case 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:13.1.28 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
CD.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, <i>e.g.</i> a cathetertip, this source of material can be recorded here.
898201001 Specimen from device
List2.png SpecimenSourceCodelist
ST.png NL-CM:13.1.19 Arrowright.pngComment 0..1 Comments on the specimen , 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 TestCodeNHGCodelist
List2.png TestNameLOINCCodelist
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).
List2.png TestResultCodelist
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 a panel/cluster, the overall status is given in the status of the panel/cluster.
92236-9 Lab observation result status
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:13.1.14 Arrowright.pngResultFlags 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. 
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 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.
92235-1 Lab order result status
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, <i>e.g.</i> paired tests or sequential tests like gram staining and microbiological cultures. It concerns previous results that collectively lead to the current interpretation.
Block.png LaboratoryTestResult
Verwijzing.png NL-CM:13.1.35 Arrowright.pngPerformer::HealthcareProvider 0..1 The healthcare provider who is responsible for the excecution of the laboratory examination and delivering the Laboratory result.
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

Voorbeeld file fout: Unable to find the specified file. : nl.zorg.Zib of versie niet gevonden-v6.0(NL)_Voorbeeld.docx

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: Required
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: Required
Conceptname Codesystem name Codesystem OID
SNOMED CT: <434711009|Specimen container| SNOMED CT 2.16.840.1.113883.6.96

MicroorganismCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.10 Binding: Required
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: Required
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: Required
Conceptname Codesystem name Codesystem OID
All values 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

SpecimenMaterialCodelist

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

SpecimenSourceCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.18 Binding: Required
Conceptname Codesystem name Codesystem OID
SNOMED CT: <<125676002|Person| SNOMED CT 2.16.840.1.113883.6.96
SNOMED CT: <<260787004|Physical object| SNOMED CT 2.16.840.1.113883.6.96
SNOMED CT: <<276339004|Environment| SNOMED CT 2.16.840.1.113883.6.96

TestCodeNHGCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.16 Binding: Required
Conceptname Codesystem name Codesystem OID
Alle labbepaling waarden NHG tabel 45 2.16.840.1.113883.2.4.4.30.45

Note: These are the values of which the field "Soort" contains the letter "L"

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
SNOMED CT: ^260131000146101|Dutch laboratory test method simple reference set| SNOMED CT 2.16.840.1.113883.6.96

TestNameLOINCCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.3 Binding: Required
Conceptname Codesystem name Codesystem OID
All values Nederlandse Labcodeset 2.16.840.1.113883.2.4.3.11.51.1

TestResultCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.17 Binding: Required
Conceptname Codesystem name Codesystem OID
Refset: SNOMED CT: ^2581000146104|Dutch microorganism simple reference set| SNOMED CT 2.16.840.1.113883.6.96
Refset: SNOMED CT: ^46231000146109|Dutch ordinal test result simple reference set| SNOMED CT 2.16.840.1.113883.6.96
Refset: SNOMED CT: ^97801000146108|Dutch microscopic ordinal test result simple reference set| SNOMED CT 2.16.840.1.113883.6.96
Refset: SNOMED CT: ^140301000146101|Dutch simple reference set for ordinal antimicrobial susceptibility test results| SNOMED CT 2.16.840.1.113883.6.96
Refset: SNOMED CT: ^145871000146106|Dutch mixed flora finding simple reference set| SNOMED CT 2.16.840.1.113883.6.96

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

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Technical specifications in HL7v3 CDA and HL7 FHIR

To exchange information based on health and care information models, additional, more technical specifications are required.<BR> 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
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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 Pre-release 2022-1
SNOMED CT and LOINC codes are based on:

  • SNOMED Clinical Terms versie: 20230930 [R] (september 2023-editie)
  • LOINC version 2.76

Conditions for use are located on the mainpage List2.png
This page is generated on 27/03/2024 11:09:50 with ZibExtraction v. 9.3.8851.20230

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