LaboratoryTestResultForTransfer-v3.0(2016EN)

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General information

Name: nl.zorg.LaboratoryTestResultForTransfer NL.png
Version: 3.0
HCIM Status:Final
Release: 2016
Release status: Published
Release date: 1-5-2016

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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.OverdrachtLaboratoriumUitslag
DCM::PublicationDate 1-5-2016
DCM::PublicationStatus Published
DCM::ReviewerList Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate 25-8-2015
DCM::Superseeds nl.nfu.OverdrachtLaboratoriumUitslag-v1.2.2
DCM::Version 3.0
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)

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-453 Wijziging naamgeving ZIB's en logo's door andere opzet van beheer

.

Concept

A laboratory result describes the result of a laboratory analysis.
In addition to the results of tests with a singular result, the results of more complex tests with multiple results or a ‘panel’ can also be recorded.

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: TextResultTransfer and LaboratoryResultTransfer.

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 TextResultTransfer 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 TextResultTransfer 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.

In developing the information model, the definitions were used from the data set and coding choices from the IHE/Nictiz e-Lab program.
The now determined information model is a subset of the e-Lab data set, provided that the detailing that is less relevant to the general transfer use case was left out. If this information is required, it can be entered in the comments field.

Information Model


#ResultStatusCodelist#TestCodelist#10897#10919#ResultTypeCodelist#10899#10911#10896#10892#10895LaboratoryTestResultForTransfer-v3.0Model(2016EN).png
#TestNameCodelist#TestMethodCodelist#ResultFlagsCodelist#10913#10910#10911#10909#10903#10905#10907#10915LaboratoriumTest-v3.0Model(2016EN).png
#DrawingProcedureCodelist#SpecimenMaterialCodelist#10919#10918#10920#10921#10916#10917Monster-v3.0Model(2016EN).png


Type Id Concept Card. Definition DefinitionCode Reference
Block.png NL-CM:13.1.1 Arrowdown.pngLaboratoryTestResult Root concept of the LaboratoryTestResultTransfer information model. This root concept contains all data elements of the Laboratory TestResultTransfer information model.
Folder.png NL-CM:13.1.2 Arrowdown.pngSpecimen 1 Container of the Specimen concept. This container contains all data elements of the Specimen concept.
II.png NL-CM:13.1.15 Arrowright.pngSpecimenNumber 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.
CD.png NL-CM:13.1.16 Arrowright.pngSpecimenMaterial 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.

List2.png SpecimenMaterialCodelist
TS.png NL-CM:13.1.17 Arrowright.pngDrawingDateTime 1 Time at which the material was drawn.
399445004 specimen collection date
CD.png NL-CM:13.1.18 Arrowright.pngDrawingProcedure 0..1 If relevant for the results, the method of obtaining the specimen can be entered as well.
List2.png DrawingProcedureCodelist
ST.png NL-CM:13.1.19 Arrowright.pngExplanation 0..1 Comments on administering the test, such as drawing material after a (glucose) stimulus or taking medicine.
48767-8 Annotation comment
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.pngTestName 1 The TestName is the name 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.
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.pngResult 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).
ANY.png NL-CM:13.1.11 Arrowright.pngUpperReferenceLimit 0..1 The upper reference limit for the patient of the value measured in the test.
ANY.png NL-CM:13.1.12 Arrowright.pngLowerReferenceLimit 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..* Attention codes indicating whether the result is above or below certain reference values.
List2.png ResultFlagsCodelist
CD.png NL-CM:13.1.4 Arrowright.pngTest 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 TestCodelist
CD.png NL-CM:13.1.6 Arrowright.pngResultStatus 0..1 The status of the laboratory test result.
List2.png ResultStatusCodelist
ST.png NL-CM:13.1.5 Arrowright.pngExplanation 0..1 Comments, such as a textual interpretation or advice accompanying the result, for example.
48767-8 Annotation comment
CD.png NL-CM:13.1.7 Arrowright.pngResultType 1 The type of result defines the laboratory specialty under which the test is categorized.
List2.png ResultTypeCodelist

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 		TestNaam Test
DatumTijd 		Uitslag Referentie
Ondergrens 		Referentie
Bovengrens 		Resultaat
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 		TestNaam Test
DatumTijd 		Uitslag Referentie
Ondergrens 		Referentie
Bovengrens 		Resultaat
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 		TestNaam Test
DatumTijd 		Uitslag Referentie
Ondergrens 		Referentie
Bovengrens 		Resultaat
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

DrawingProcedureCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.2 Binding:
Conceptname Codesystem name Codesystem OID
SNOMED CT: <17636008|specimen collection| SNOMED CT 2.16.840.1.113883.6.96

ResultFlagsCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.7 Binding:
Conceptname Conceptcode Codesystem name Codesystem OID Description
High H ObservationInterpretation 2.16.840.1.113883.5.83 Boven referentiewaarde
Low L ObservationInterpretation 2.16.840.1.113883.5.83 Onder referentiewaarde
Intermediate I ObservationInterpretation 2.16.840.1.113883.5.83 Variabel
Resistant R ObservationInterpretation 2.16.840.1.113883.5.83 Resistent
Susceptible S ObservationInterpretation 2.16.840.1.113883.5.83 Sensitief

ResultStatusCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.8 Binding:
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:
Conceptname Conceptcode Codesystem name Codesystem OID Description
Hematology 252275004 SNOMED CT 2.16.840.1.113883.6.96 Hematologie
Chemistry 275711006 SNOMED CT 2.16.840.1.113883.6.96 Klinische chemie
Serology 68793005 SNOMED CT 2.16.840.1.113883.6.96 Serologie/ immunologie
Virology 395124008 SNOMED CT 2.16.840.1.113883.6.96 Virologie
Toxicology 314076009 SNOMED CT 2.16.840.1.113883.6.96 Toxicologie
Microbiology 19851009 SNOMED CT 2.16.840.1.113883.6.96 Microbiologie

SpecimenMaterialCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.6 Binding:
Conceptname Codesystem name Codesystem OID
SNOMED CT: <123038009|specimen| SNOMED CT 2.16.840.1.113883.6.96

TestCodelist

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

TestMethodCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.4 Binding:
Conceptname Codesystem name Codesystem OID
Alle waarden 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:
Conceptname Codesystem name Codesystem OID
Alle waarden LOINC 2.16.840.1.113883.6.1

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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.
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

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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 Release summer 2016
Conditions for use are located on the mainpage List2.png
This page is generated on 21/12/2018 15:40:38 with ZibExtraction v. 3.0.6929.24609

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