Be.en.hd.TransferLaboratoryResult

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General

Name: be.en.hd.TransferLaboratoryResult
Version: 0.0.1
Status: Draft

Metadata

DCM::CoderList healthdata.be
DCM::ContactInformation.Address *
DCM::ContactInformation.Name *
DCM::ContactInformation.Telecom *
DCM::ContentAuthorList Clinical Building Blocks Expert Group & healthdata.be
DCM::CreationDate 7-6-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage en
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name healthdata.be
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 Draft
DCM::ModelerList Clinical Building Blocks Expert Group & healthdata.be
DCM::Name be.en.hd.TransferLaboratoryResult
DCM::PublicationDate
DCM::PublicationStatus
DCM::ReviewerList Clinical Building Blocks Expert Group & healthdata.be
DCM::RevisionDate 05-01-2016
DCM::Superseeds
DCM::Version 0.0.1

Revision History

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.

Information model

Be.en.hd.TransferLaboratoryResultModel.png
Refer to the legend page for more information about the used types and data types

rootconcept LaboratoryTestResult
Definition Root concept of the LaboratoryTestResultTransfer building block. This root concept contains all data elements of the Laboratory TestResultTransfer building block.
Type Zib.png
data Explanation
Definition Comments, such as a textual interpretation or advice accompanying the result, for example.
Datatype ST.png
data Test
Definition 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.
Datatype CD.png
DCM::ExampleValue Bloedgassen
DCM::ValueSet File:List.png TestCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.5
data ResultStatus
Definition The status of the laboratory test result.
Datatype CD.png
DCM::ExampleValue Definitief
DCM::ValueSet File:List.png ResultStatusCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.8
data ResultType
Definition The type of result defines the laboratory specialty under which the test is categorized.
Datatype CD.png
DCM::ExampleValue Klinische Chemie
DCM::ValueSet File:List.png ResultTypeCodeList OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.1

LaboratoryTest

Be.en.hd.TransferLaboratoryResultLaboratoryTestModel.png
Refer to the legend page for more information about the used types and data types

container LaboratoryTest
Definition Container of the LaboratoryTest concept. This container contains all data elements of the LaboratoryTest concept.
Datatype Container.png
data TestDateTime
Definition The date and if possible the time at which the test was carried out.
Datatype TS.png
DCM::ExampleValue 10-07-2012 20:15
data Result
Definition 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).
Datatype 16px
DCM::ExampleValue 53 mmol/mol
data UpperReferenceLimit
Definition The upper reference limit for the patient of the value measured in the test.
Datatype 16px
DCM::ExampleValue 42 mmol/mol
data LowerReferenceLimit
Definition The lower reference limit for the patient of the value measured with the test.
Datatype 16px
DCM::ExampleValue 20 mmol/mol
data TestName
Definition The TestName is the name of the executed test.
Datatype CD.png
DCM::ExampleValue HbA1c
DCM::ValueSet File:List.png TestNaamCodelijst OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.3
data TestMethod
Definition The test method used to obtain the result.
Datatype CD.png
DCM::ExampleValue IFCC
DCM::ValueSet File:List.png TestmethodeCodelijst OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.4
data ResultFlags
Definition Attention codes indicating whether the result is above or below certain reference values.
Datatype CD.png
DCM::ExampleValue High
DCM::ValueSet File:List.png ResultaatVlaggenCodelijst OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.7

Specimen

Be.en.hd.TransferLaboratoryResultSpecimenModel.png
Refer to the legend page for more information about the used types and data types

container Specimen
Definition Container of the Specimen concept. This container contains all data elements of the Specimen concept.
Datatype Container.png
data SpecimenNumber
Definition 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.
Datatype 16px
data DrawingDateTime
Definition Time at which the material was drawn.
Datatype TS.png
DCM::ExampleValue 10-07-2012 17:20
data Explanation
Definition Comments, such as a textual interpretation or advice accompanying the result, for example.
Datatype ST.png
DCM::ExampleValue Na (glucose)stimulus
data SpecimenMaterial
Definition 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.

Datatype CD.png
DCM::ExampleValue Urine
DCM::ValueSet File:List.png MonstermateriaalCodelijst OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.6
data DrawingProcedure
Definition If relevant for the results, the method of obtaining the specimen can be entered as well.
Datatype CD.png
DCM::ExampleValue Midstream
DCM::ValueSet File:List.png AfnameprocedureCodelijst OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.2

Code Lists

ResultStatusCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.13.1.8

Concept Name Concept Code CodeSys. 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

TestCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.13.1.5

Codes Coding Syst. Name Coding System OID
Alle waarden LOINC 2.16.840.1.113883.6.1

ResultTypeCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.13.1.1

Concept Name Concept Code Coding Syst. Name Coding System OID Omschrijving
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

TestMethodCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.13.1.4

Codes Coding Syst. Name Coding System OID
Alle waarden SNOMED CT 2.16.840.1.113883.6.96

TestNameCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.13.1.3

Codes Coding Syst. Name Coding System OID
Alle waarden LOINC 2.16.840.1.113883.6.1

ResultFlagsCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.13.1.7

Concept Name Concept Code Coding Syst. Name Coding System OID Description
High 75540009 SNOMED CT 2.16.840.1.113883.5.83 Boven referentiewaarde
Low 62482003 SNOMED CT 2.16.840.1.113883.5.83 Onder referentiewaarde
Intermediate 11896004 SNOMED CT 2.16.840.1.113883.5.83 Variabel
Resistant 30714006 SNOMED CT 2.16.840.1.113883.5.83 Resistent
Susceptible 131196009 SNOMED CT 2.16.840.1.113883.5.83 Sensitief

DrawingProcedureCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.13.1.2

Codes Coding Syst. Name Coding System OID
specimen collection |SNOMED CT 2.16.840.1.113883.6.96

SpecimenMaterialCodeList

OID:2.16.840.1.113883.2.4.3.11.60.40.2.13.1.6

Codes Coding Syst. Name Coding System OID
specimen |SNOMED CT 2.16.840.1.113883.6.96

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].