| TEMPLATE ID | nyrebiopsiregister, klinisk skjema |
|---|---|
| Concept | nyrebiopsiregister, klinisk skjema |
| Description | Not Specified |
| Purpose | Not Specified |
| References | |
| Other Details (Language Independent) |
|
| Language used | nb |
| Citeable Identifier | 1078.60.429 |
| Root archetype id | openEHR-EHR-COMPOSITION.report-procedure.v1 |
| Norsk nyrebiopsiregister, klinisk skjema | Norsk nyrebiopsiregister, klinisk skjema: Document to communicate information to others about any stand-alone procedure or operation performed. |
| Other Context | |
| Report ID | Report ID: Identification information about the report. |
| Status | Status: The status of the entire report. Note: This is not the status of any of the report components. |
| Generelle opplysninger | Generelle opplysninger: A generic section header. |
| Biopsiteknikk og lokalisering | Biopsiteknikk og lokalisering: A generic section header. |
| Prosedyre | Prosedyre: En klinisk aktivitet some er utført for terapeutiske eller diagnostiske formål. |
| Description | |
| Prosedyre | Prosedyre: Navnet på prosedyren. |
| Indikasjonen for prosedyren | Indikasjonen for prosedyren: Indikasjon for prosedyren. |
| Metode/teknikk | Metode/teknikk: Identifikasjon av spesifikk metode eller teknikk for prosedyren. |
| Beskrivelse | Beskrivelse: Tekstlig beskrivelse av den utførte prosedyren. |
| Ytterligere aktiviteter | Ytterligere aktiviteter: Registrere informasjon om ikke-planlagte eller uventede aktiviteter som måtte gjøres i forbindelse med inngrepet. Noter navnet på aktiviteten og en beskrivelse innen arketypen. Detaljene om aktiviteten bør registreres i spesifikke knyttet INSTRUCTION- eller ACTION-arketyper. |
| Aktivitet | Aktivitet: Navnet på den ekstra aktivitet som er utført under prosedyren. |
| Aktivitetsbeskrivelse | Aktivitetsbeskrivelse: Beskrivelse av den ekstra aktivitet som er utført under prosedyren. |
| Registrering av ekstra aktivitet | Registrering av ekstra aktivitet: Lenke til den detaljerte dokumentasjon for den ekstra aktivitet. |
| Resultat | Resultat: Resultatet av den utførte prosedyren. |
| Prosedyre mislyktes | Prosedyre mislyktes: Var prosedyren til slutt mislykket? Verdien skal være "sann" hvis mislykket. |
| Uventet hendelse | Uventet hendelse: En uforutsett hendelse før eller knyttet til prosedyren som kunne påvirke gjennomføringen, f.eks pasienten selv fjernet kanylen. |
| Komplikasjon | Komplikasjon: Detaljer om en hvilken som helst komplikasjon på grunn av prosedyren. |
| Akutt | Akutt: Var denne prosedyre utført akutt? Verdien skal være "sann" hvis ja. |
| Kommentarer | Kommentarer: Kommentarer til prosedyren. |
| Multimedia | Multimedia: Multimediavisning av prosedyren inklusive bilder. |
| Protocol | |
| Rekvirentidentifikator | Rekvirentidentifikator: Den lokale ID som tildeles rekvisisjonen av den som rekvirerer prosedyren (Den ID som den bestillende avdeling eller klinikk tildeler en rekvisisjon). |
| Mottakeridentifikator | Mottakeridentifikator: Den ID som er tildelt rekvisisjonen av den som mottar (og som skal utføre) den rekvirerte prosedyre (Mottakerens ID til en prosedyre). |
| Kliniske indikasjoner for biopsi | Kliniske indikasjoner for biopsi: A generic section header. |
| Kliniske og laboratoriedata | Kliniske og laboratoriedata: A generic section header. |
| Høyde | Høyde: Lengden av kroppen fra isse til fotsåle. 0..1000; 0..250 Enheter:
|
| Vekt | Vekt: Vekten til en person. 0..1000; 0..2000 Enheter:
|
| Blodtrykk | Blodtrykk: Måling av blodtrykket som mål for det arterielle blodtrykk i det systemiske kretsløp. Vanligvis refererer bruken av begrepet "blodtrykket" til en måling av brachialisarterietrykket på overarmen. |
| Uspesifisert hendelse | Uspesifisert hendelse: Standardhendelse |
| Systolisk | Systolisk: Maksimalt systemisk arterielt blodtrykk - målt i systolen eller under hjertets kontraksjonsfase. 0..1000 mmHg |
| Diastolisk | Diastolisk: Laveste systemiske arterielle blodtrykk - målt i diastolen eller under hjertets avslapningsfase. 0..1000 mmHg |
| Blodprøver | Blodprøver: The findings and interpretation of pathology tests performed on patient-related specimens. This archetype may be used to record a single valued test, but will often be specialised or templated to represent multiple value or 'panel' tests. This archetype also acts as the parent for specialisations appropriate for more specific laboratory tests, e.g. microbiology, histopathology. |
| S-kreatinin | S-kreatinin: Any event. |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". Standard verdi: NPU04998 |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Value | Result Value: Actual value of the result. Most result values will be numerical measurements, but others may be coded concepts, free text, or multimedia images. Enheter: {AMOUNT (mole)/VOLUME} |
| S-kolesterol | S-kolesterol: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| S-albumin | S-albumin: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| ANA | ANA: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| Anti-GBM | Anti-GBM: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| Proteinase3-ANCA | Proteinase3-ANCA: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| Myeloperoksidase-ANCA | Myeloperoksidase-ANCA: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| C3 | C3: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| C4 | C4: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| IgG | IgG: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| IgA | IgA: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| IgM | IgM: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| Målt GFR | Målt GFR: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| Urinprøver | Urinprøver: The findings and interpretation of pathology tests performed on patient-related specimens. This archetype may be used to record a single valued test, but will often be specialised or templated to represent multiple value or 'panel' tests. This archetype also acts as the parent for specialisations appropriate for more specific laboratory tests, e.g. microbiology, histopathology. |
| Data | |
| Protein/kreatinin ratio | Protein/kreatinin ratio: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| Protein | Protein: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| Albumin | Albumin: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| Albumin/kreatinin ratio | Albumin/kreatinin ratio: Any event. |
| Data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| Protocol | |
| Test Request Details | Test Request Details: Details concerning a single pathology test requested. Usually there is one test request (or "order") for each result, however in some circumstances multiple test requests may be represented using a single Pathology test result archetype. |
| Requester Order Identifier | Requester Order Identifier: The local ID assigned to the order by the order requester. Equivalent to the Placer Order Identifier. |
| Test Requested Name | Test Requested Name: Identification of pathology test requested, where the test requested differs from the test actually performed. |
| Receiver Order Identifier | Receiver Order Identifier: The local ID assigned to the test order by the order filler, usually by the Laboratory Information System (LIS). Assigning an identifier to a request by the Radiology lnformation System enables tracking progress of the request and enables linking results to requests. It also provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler Order Identifier. |
| Laboratory Test Result Identifier | Laboratory Test Result Identifier: The identifier given to the laboratory test result of a pathology investigation. |
| Antatt diagnose | Antatt diagnose: A generic section header. |
| Rapportert av | Rapportert av: A generic section header. |