diff --git a/grails-app/controllers/com/cabolabs/ehrserver/api/RestController.groovy b/grails-app/controllers/com/cabolabs/ehrserver/api/RestController.groovy
index b7db2edd0..12cfd62bb 100644
--- a/grails-app/controllers/com/cabolabs/ehrserver/api/RestController.groovy
+++ b/grails-app/controllers/com/cabolabs/ehrserver/api/RestController.groovy
@@ -1873,7 +1873,7 @@ class RestController {
return
}
- def opt_out = optService.getOPTContents(opt)
+ def opt_out = optService.getOPTContents(opt, -1)
withFormat {
xml {
diff --git a/grails-app/controllers/com/cabolabs/ehrserver/openehr/ehr/OperationalTemplateController.groovy b/grails-app/controllers/com/cabolabs/ehrserver/openehr/ehr/OperationalTemplateController.groovy
index b5adfbe95..a72e4fa75 100644
--- a/grails-app/controllers/com/cabolabs/ehrserver/openehr/ehr/OperationalTemplateController.groovy
+++ b/grails-app/controllers/com/cabolabs/ehrserver/openehr/ehr/OperationalTemplateController.groovy
@@ -286,18 +286,20 @@ class OperationalTemplateController {
def opt = OperationalTemplateIndex.findByLocalUidAndOrganizationUid(uid, session.organization.uid)
if (!opt)
{
+ println "no opt"
flash.message = message(code:"opt.common.error.templateNotFound")
redirect action:'index'
return
}
if (!opt.lastVersion)
{
+ println "no last version"
flash.message = message(code:"opt.common.error.templateNotLastVersion")
redirect action:'index'
return
}
- def opt_xml = optService.getOPTContents(opt)
+ def opt_xml = optService.getOPTContents(opt, -1)
// get all versions of the OPT, including last (current opt uid)
def versions = OperationalTemplateIndex.findAllBySetId(opt.setId, [sort: 'versionNumber', order: 'desc'])
diff --git a/grails-app/jobs/com/cabolabs/indexing/OperationalTemplateIndexerJob.groovy b/grails-app/jobs/com/cabolabs/indexing/OperationalTemplateIndexerJob.groovy
index 360f7ebc9..27de182f8 100644
--- a/grails-app/jobs/com/cabolabs/indexing/OperationalTemplateIndexerJob.groovy
+++ b/grails-app/jobs/com/cabolabs/indexing/OperationalTemplateIndexerJob.groovy
@@ -26,14 +26,16 @@ class OperationalTemplateIndexerJob {
opts.each { optIndex ->
- println "Indexing ${optIndex.templateId}"
+ println "Indexing ${optIndex.templateId} ${optIndex.fileLocation}"
// FIXME: this is a terrible way of saying "do not create the OPTIndex", that should be a parameter or something else...
// Generates OPT and archetype item indexes just for the uploaded OPT
operationalTemplateIndexerService.templateIndex = optIndex // avoids creating another opt index internally and use the one created here
- xml = optService.getOPTContents(optIndex)
+ xml = optService.getOPTContents(optIndex, -1)
+ println xml
+
template = slurper.parseText(xml)
diff --git a/grails-app/services/com/cabolabs/ehrserver/openehr/OptFSService.groovy b/grails-app/services/com/cabolabs/ehrserver/openehr/OptFSService.groovy
index 7fd872e38..26d5122cd 100644
--- a/grails-app/services/com/cabolabs/ehrserver/openehr/OptFSService.groovy
+++ b/grails-app/services/com/cabolabs/ehrserver/openehr/OptFSService.groovy
@@ -17,7 +17,7 @@ class OptFSService {
String getOPTContents(OperationalTemplateIndex opt, int max_bytes_to_return = 1000000)
{
// avoid returning files that are too big
- if (new File(opt.fileLocation).length() > max_bytes_to_return)
+ if (max_bytes_to_return > 0 && opt.size > max_bytes_to_return)
{
return
}
diff --git a/grails-app/services/com/cabolabs/ehrserver/openehr/OptS3Service.groovy b/grails-app/services/com/cabolabs/ehrserver/openehr/OptS3Service.groovy
index 66c07391f..78a33e81d 100644
--- a/grails-app/services/com/cabolabs/ehrserver/openehr/OptS3Service.groovy
+++ b/grails-app/services/com/cabolabs/ehrserver/openehr/OptS3Service.groovy
@@ -19,7 +19,7 @@ class OptS3Service {
def operationalTemplateIndexer
- // TODO: refactor, these are the same as the ones in VersionFSRepoService, just the repo field changes.
+ // TODO: refactor, these methods are implemented in OptRepositoryS3Impl, we could use that one instead of repeating the code
AmazonS3 s3
// this initalizes the S3 connection when the service is created
diff --git a/grails-app/services/com/cabolabs/ehrserver/sync/SyncParserService.groovy b/grails-app/services/com/cabolabs/ehrserver/sync/SyncParserService.groovy
index 7b6fc4cac..501b022d3 100644
--- a/grails-app/services/com/cabolabs/ehrserver/sync/SyncParserService.groovy
+++ b/grails-app/services/com/cabolabs/ehrserver/sync/SyncParserService.groovy
@@ -327,6 +327,7 @@ class SyncParserService {
return eq
}
+ // FIXME: sync should send the OPT files and generate these indexes in the slave server, instead of creating them in the master and send them.
OperationalTemplateIndex toJSONOpt(JSONObject j)
{
def templateIndex = new OperationalTemplateIndex(
@@ -344,7 +345,8 @@ class SyncParserService {
setId: j.setId,
versionNumber: j.versionNumber,
lastVersion: j.lastVersion,
- fileLocation: j.fileLocation
+ fileLocation: j.fileLocation,
+ size: j.size
)
def xml = j.opt
diff --git a/grails-app/services/com/cabolabs/opt/OperationalTemplateIndexerService.groovy b/grails-app/services/com/cabolabs/opt/OperationalTemplateIndexerService.groovy
index 47714fe65..3ef4c5f4d 100644
--- a/grails-app/services/com/cabolabs/opt/OperationalTemplateIndexerService.groovy
+++ b/grails-app/services/com/cabolabs/opt/OperationalTemplateIndexerService.groovy
@@ -345,7 +345,7 @@ class OperationalTemplateIndexerService {
opt.isActive = true
opt.save(flush: true, failOnError: true)
- def opt_xml = optService.getOPTContents(opt)
+ def opt_xml = optService.getOPTContents(opt, -1)
def org = Organization.findByUid(opt.organizationUid)
def clean_opt_xml = FileUtils.removeBOM(opt_xml.getBytes())
@@ -450,6 +450,8 @@ class OperationalTemplateIndexerService {
// if it is not coming from an alraedy indexed OPT
if (!this.templateIndex)
{
+ def fileLocation = optService.newOPTFileLocation(org.uid, templateId)
+
this.templateIndex = new OperationalTemplateIndex(
localTemplateId: localTemplateId,
templateId: templateId,
@@ -459,7 +461,8 @@ class OperationalTemplateIndexerService {
archetypeId: archetypeId,
archetypeConcept: archetypeConcept,
organizationUid: org.uid,
- fileLocation: optService.newOPTFileLocation(org.uid, templateId)
+ fileLocation: fileLocation,
+ size: new File(fileLocation).length() // FIXME: this doesn't work for S3 storage!
)
// TODO: log errors and throw except
diff --git a/grails-app/views/operationalTemplate/upload.gsp b/grails-app/views/operationalTemplate/upload.gsp
index 40906d1c9..2fb7a3375 100644
--- a/grails-app/views/operationalTemplate/upload.gsp
+++ b/grails-app/views/operationalTemplate/upload.gsp
@@ -96,9 +96,12 @@
var input = $(this).parents('.input-group').find(':text'),
log = numFiles > 1 ? numFiles + ' files selected' : label;
- if( input.length ) {
+ if (input.length)
+ {
input.val(log);
- } else {
+ }
+ else
+ {
if (log)
{
new PNotify({
@@ -169,6 +172,7 @@
'
'+
data.message +'
'
);
+ console.log("redirect: ", data);
location.href = '${createLink("action": "show")}/'+ data.opt.localUid;
}
else if (data.status == "error")
diff --git a/opts/base_opts/tmp/control_del_peso.es.v1.opt b/opts/base_opts/control_del_peso.es.v1.opt
similarity index 100%
rename from opts/base_opts/tmp/control_del_peso.es.v1.opt
rename to opts/base_opts/control_del_peso.es.v1.opt
diff --git a/opts/base_opts/datos_demograficos.es.v2.opt b/opts/base_opts/tmp/datos_demograficos.es.v2.opt
similarity index 100%
rename from opts/base_opts/datos_demograficos.es.v2.opt
rename to opts/base_opts/tmp/datos_demograficos.es.v2.opt
diff --git a/opts/base_opts/lab_results.en.v1.opt b/opts/base_opts/tmp/lab_results.en.v1.opt
similarity index 100%
rename from opts/base_opts/lab_results.en.v1.opt
rename to opts/base_opts/tmp/lab_results.en.v1.opt
diff --git a/opts/base_opts/placeholder b/opts/base_opts/tmp/placeholder
similarity index 100%
rename from opts/base_opts/placeholder
rename to opts/base_opts/tmp/placeholder
diff --git a/opts/base_opts/problem_list.en.v1.opt b/opts/base_opts/tmp/problem_list.en.v1.opt
similarity index 100%
rename from opts/base_opts/problem_list.en.v1.opt
rename to opts/base_opts/tmp/problem_list.en.v1.opt
diff --git a/opts/base_opts/review.en.v1.opt b/opts/base_opts/tmp/review.en.v1.opt
similarity index 100%
rename from opts/base_opts/review.en.v1.opt
rename to opts/base_opts/tmp/review.en.v1.opt
diff --git a/opts/base_opts/screening.en.v1.opt b/opts/base_opts/tmp/screening.en.v1.opt
similarity index 100%
rename from opts/base_opts/screening.en.v1.opt
rename to opts/base_opts/tmp/screening.en.v1.opt
diff --git a/opts/base_opts/signos.es.v1.opt b/opts/base_opts/tmp/signos.es.v1.opt
similarity index 100%
rename from opts/base_opts/signos.es.v1.opt
rename to opts/base_opts/tmp/signos.es.v1.opt
diff --git a/opts/base_opts/simple_encounter.en.v1.opt b/opts/base_opts/tmp/simple_encounter.en.v1.opt
similarity index 100%
rename from opts/base_opts/simple_encounter.en.v1.opt
rename to opts/base_opts/tmp/simple_encounter.en.v1.opt
diff --git a/opts/base_opts/simple_encounter.es.v1.opt b/opts/base_opts/tmp/simple_encounter.es.v1.opt
similarity index 100%
rename from opts/base_opts/simple_encounter.es.v1.opt
rename to opts/base_opts/tmp/simple_encounter.es.v1.opt
diff --git a/opts/base_opts/simple_lab_order.en.v1.opt b/opts/base_opts/tmp/simple_lab_order.en.v1.opt
similarity index 100%
rename from opts/base_opts/simple_lab_order.en.v1.opt
rename to opts/base_opts/tmp/simple_lab_order.en.v1.opt
diff --git a/opts/base_opts/simple_vaccination_record.en.v1.opt b/opts/base_opts/tmp/simple_vaccination_record.en.v1.opt
similarity index 100%
rename from opts/base_opts/simple_vaccination_record.en.v1.opt
rename to opts/base_opts/tmp/simple_vaccination_record.en.v1.opt
diff --git a/opts/base_opts/sinais_vitais_fhvc.en.v1.opt b/opts/base_opts/tmp/sinais_vitais_fhvc.en.v1.opt
similarity index 100%
rename from opts/base_opts/sinais_vitais_fhvc.en.v1.opt
rename to opts/base_opts/tmp/sinais_vitais_fhvc.en.v1.opt
diff --git a/opts/base_opts/sinais_vitais_wout_proportion_fhvc.en.v4.opt b/opts/base_opts/tmp/sinais_vitais_wout_proportion_fhvc.en.v4.opt
similarity index 100%
rename from opts/base_opts/sinais_vitais_wout_proportion_fhvc.en.v4.opt
rename to opts/base_opts/tmp/sinais_vitais_wout_proportion_fhvc.en.v4.opt
diff --git a/opts/base_opts/test_all_datatypes.en.v1.opt b/opts/base_opts/tmp/test_all_datatypes.en.v1.opt
similarity index 100%
rename from opts/base_opts/test_all_datatypes.en.v1.opt
rename to opts/base_opts/tmp/test_all_datatypes.en.v1.opt
diff --git a/opts/base_opts/test_all_datatypes.es.v1.opt b/opts/base_opts/tmp/test_all_datatypes.es.v1.opt
similarity index 100%
rename from opts/base_opts/test_all_datatypes.es.v1.opt
rename to opts/base_opts/tmp/test_all_datatypes.es.v1.opt
diff --git a/opts/base_opts/test_index_admin_entry.en.v1.opt b/opts/base_opts/tmp/test_index_admin_entry.en.v1.opt
similarity index 100%
rename from opts/base_opts/test_index_admin_entry.en.v1.opt
rename to opts/base_opts/tmp/test_index_admin_entry.en.v1.opt
diff --git a/opts/base_opts/test_index_interval_event.en.v1.opt b/opts/base_opts/tmp/test_index_interval_event.en.v1.opt
similarity index 100%
rename from opts/base_opts/test_index_interval_event.en.v1.opt
rename to opts/base_opts/tmp/test_index_interval_event.en.v1.opt
diff --git a/opts/base_opts/test_index_references.en.v1.opt b/opts/base_opts/tmp/test_index_references.en.v1.opt
similarity index 100%
rename from opts/base_opts/test_index_references.en.v1.opt
rename to opts/base_opts/tmp/test_index_references.en.v1.opt
diff --git a/opts/base_opts/test_index_references.es.v1.opt b/opts/base_opts/tmp/test_index_references.es.v1.opt
similarity index 100%
rename from opts/base_opts/test_index_references.es.v1.opt
rename to opts/base_opts/tmp/test_index_references.es.v1.opt
diff --git a/opts/base_opts/test_indexing_evaluation.es.v1.opt b/opts/base_opts/tmp/test_indexing_evaluation.es.v1.opt
similarity index 100%
rename from opts/base_opts/test_indexing_evaluation.es.v1.opt
rename to opts/base_opts/tmp/test_indexing_evaluation.es.v1.opt
diff --git a/opts/base_opts/test_indexing_section.en.v1.opt b/opts/base_opts/tmp/test_indexing_section.en.v1.opt
similarity index 100%
rename from opts/base_opts/test_indexing_section.en.v1.opt
rename to opts/base_opts/tmp/test_indexing_section.en.v1.opt
diff --git a/opts/base_opts/test_ism_paths.es.v1.opt b/opts/base_opts/tmp/test_ism_paths.es.v1.opt
similarity index 100%
rename from opts/base_opts/test_ism_paths.es.v1.opt
rename to opts/base_opts/tmp/test_ism_paths.es.v1.opt
diff --git a/opts/base_opts/teste_fh_1.en.v1.opt b/opts/base_opts/tmp/teste_fh_1.en.v1.opt
similarity index 100%
rename from opts/base_opts/teste_fh_1.en.v1.opt
rename to opts/base_opts/tmp/teste_fh_1.en.v1.opt
diff --git a/opts/base_opts/vital_signs.en.v1.opt b/opts/base_opts/tmp/vital_signs.en.v1.opt
similarity index 100%
rename from opts/base_opts/vital_signs.en.v1.opt
rename to opts/base_opts/tmp/vital_signs.en.v1.opt
diff --git a/opts/base_opts/tmp/vital_signs_summary.en.v1.opt b/opts/base_opts/tmp/vital_signs_summary.en.v1.opt
index 95741d135..3df5bbdad 100644
--- a/opts/base_opts/tmp/vital_signs_summary.en.v1.opt
+++ b/opts/base_opts/tmp/vital_signs_summary.en.v1.opt
@@ -1,4 +1,4 @@
-
+
@@ -6638,7 +6638,7 @@
openEHR-EHR-COMPOSITION.health_summary.v1
- vital_signs_summary.en.v1
+ Vital_Signs_Summary.EN.v1Generic document containing a summary of health information about an individual.
@@ -6706,4 +6706,4 @@
-
+
\ No newline at end of file
diff --git a/opts/base_opts/vital_signs_summary.en.v1.opt b/opts/base_opts/vital_signs_summary.en.v1.opt
deleted file mode 100644
index 3df5bbdad..000000000
--- a/opts/base_opts/vital_signs_summary.en.v1.opt
+++ /dev/null
@@ -1,6709 +0,0 @@
-
-
-
-
-
- ISO_639-1
-
- en
-
-
- Not Specified
- Initial
- Template metadata sample set
-
-
-
-
-
-
-
-
-
-
-
-
-
-
- ISO_639-1
-
- en
-
- Not Specified
-
-
-
- 77705d18-13b7-46c9-9950-1cc7d1ed8238
-
-
- vital_signs_summary.en.v1
-
- Vital Signs Summary
-
- COMPOSITION
-
- true
- true
- false
- false
- 1
- 1
-
- at0000
-
- category
-
- true
- true
- false
- false
- 1
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- openehr
-
- 433
-
-
-
-
-
- context
-
- true
- true
- false
- false
- 0
- 1
-
-
- EVENT_CONTEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- other_context
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0001
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- CLUSTER
-
- true
- false
- true
- 0
-
- at0002
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- .*
-
- constraint
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
-
-
- content
-
- true
- true
- false
- false
- 0
- 1
-
-
- SECTION
-
- true
- false
- true
- 0
-
- at0000
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- OBSERVATION
-
- true
- false
- true
- 0
-
- at0000
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- HISTORY
-
- true
- true
- false
- false
- 1
- 1
-
- at0001
-
- events
-
- true
- true
- false
- false
- 0
- 1
-
-
- EVENT
-
- true
- false
- true
- 0
-
- at0002
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0003
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0004
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- openehr
-
- 382
-
-
-
- true
- true
- false
- false
- 0
- 200
-
-
- true
- true
- false
- false
- 0
- 0
-
- /min
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0005
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- local
-
- at0006
- at0007
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0016
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- local
-
- at0017
- at0018
- at0019
- at0025
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0024
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
- state
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0022
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- CLUSTER
-
- true
- true
- false
- false
- 0
- 1
-
- at0055
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.ambient_oxygen(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- ELEMENT
-
- true
- false
- true
- 0
-
- at0056
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- CLUSTER
-
- true
- true
- false
- false
- 0
- 1
-
- at0037
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 1
-
-
-
-
-
-
- openEHR-EHR-OBSERVATION.respiration.v1
-
-
- The observed characteristics of spontaneous breathing as would commonly be recorded as part of a 'vital signs' examination.
- Respirations
-
-
- @ internal @
- history
-
-
- Generic event.
- Any event
-
-
- @ internal @
- List
-
-
- Rate of respiration.
- Rate
-
-
- Rhythm of respiration.
- Rhythm
-
-
- Regular respiration.
- Regular
-
-
- Irregular respirations.
- Irregular
-
-
- Specific abnormal respiratory pattern. Other patterns may be entered as free text or terminology subset defined at specialisation or template level.
- Abnormal respiratory pattern
-
-
- Deep chest breathing with or without a visible gasp.
- Kussmaul's respiration
-
-
- Depth of respiration.
- Depth
-
-
- Normal depth of breathing.
- Normal
-
-
- Shallow depth of breathing.
- Shallow
-
-
- Deep breathing.
- Deep
-
-
- @ internal @
- List
-
-
- A text description of respirations.
- Description
-
-
- Variable depth of breathing.
- Variable
-
-
- Periods of hyperventilation alternating with periods of apnoea.
- Cheyne-Stokes respiration
-
-
- Breathing of varying tidal volumes and rates.
- Ataxic respiration
-
-
- Deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release of breath.
- Apneustic respiration
-
-
- Clusters of irregular breaths that alternate with periods of apnoea. Also termed Biot's breathing.
- Cluster breathing
-
-
- Subject's level of exertion at or just prior to the observation being made. Intended only to record exertion only as it might effect respirations and where it would not normally be recorded as part of general clinical observation.
- Exertion
-
-
- Breathing has ceased.
- Apnoea
-
-
- The respiratory expiratory phase is longer than normal/usual. Associated with obstructive airways disease such as asthma.
- Prolonged expiratory phase
-
-
- Details of the amount of oxygen being delivered to the subject at the time of observation. Assumed values of 21% oxygen concentration, Fi02 of 0.21 and oxygen flow rate of 0 l/min or 0 ml/min.
- Ambient oxygen
-
-
- Comment on and record other incidental factors that may be contributing to the respirations observation. For example, level of anxiety, pain, feeding in infants, tracheostomy.
- Confounding factors
-
-
-
- OBSERVATION
-
- true
- false
- true
- 0
-
- at0000
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- HISTORY
-
- true
- true
- false
- false
- 1
- 1
-
- at0002
-
- events
-
- true
- true
- false
- false
- 0
- 1
-
-
- EVENT
-
- true
- false
- true
- 0
-
- at0003
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0001
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0004
-
- name
-
- true
- true
- false
- false
- 1
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- local
-
- at1026
- at1027
-
-
-
-
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- openehr
-
- 382
-
-
-
- true
- false
- true
- 0
-
-
- true
- true
- false
- false
- 0
- 0
-
- /min
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0005
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- local
-
- at0006
- at1028
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at1055
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- local
-
- at0007
- at0008
-
-
-
-
-
-
- ELEMENT
-
- true
- false
- true
- 0
-
- at1030
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at1022
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- ELEMENT
-
- true
- false
- true
- 0
-
- at1023
-
- name
-
- true
- true
- false
- false
- 1
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- local
-
- at1057
- at1058
-
-
-
-
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
- state
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0012
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0013
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- local
-
- at1001
-
-
- local
-
- at1003
- at1001
- at1002
- at1000
-
-
-
-
-
-
- ELEMENT
-
- true
- false
- true
- 0
-
- at1018
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- CLUSTER
-
- true
- false
- true
- 0
-
- at1017
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 1
-
-
-
-
-
-
- protocol
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0010
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at1019
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- local
-
- at1032
- at1033
- at1034
- at1050
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at1037
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- local
-
- at1038
- at1039
- at1040
- at1041
- at1042
- at1043
- at1044
- at1049
- at1048
- at1047
- at1054
- at1051
-
-
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- CLUSTER
-
- true
- true
- false
- false
- 0
- 1
-
- at1013
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- .*
-
- constraint
-
-
-
-
-
- CLUSTER
-
- true
- false
- true
- 0
-
- at1056
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- .*
-
- constraint
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
- openEHR-EHR-OBSERVATION.pulse.v1
-
-
- Record details about the rate and associated attributes for a pulse or heart beat.
- Pulse/Heart beat
-
-
- @ internal @
- structure
-
-
- @ internal @
- history
-
-
- Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
- Any event
-
-
- Run-time name constraints have been specified, in order to simplify the renaming of this data element to Pulse Rate or Heart Rate, as required.
- The rate, measured in beats per minute.
- Rate
-
-
- Is the pulse or heart beat regular?
- Regular?
-
-
- The pattern is regular.
- Regular
-
-
- The pattern is irregular in a regular pattern,. For example, a dropped beat once every 'n' beats.
- Regularly Irregular
-
-
- The pattern is irregular in a chaotic and unpredictable manner. For example, atrial fibrillation.
- Irregularly Irregular
-
-
- @ internal @
- List
-
-
- @ internal @
- List
-
-
- The body position of the subject during the observation.
- Position
-
-
- The subject was lying flat.
- Lying
-
-
- The subject was sitting (for example on bed or chair).
- Sitting
-
-
- The subject was reclining at an approximate angle of 45 degrees, with the legs elevated to the level of the pelvis.
- Reclining
-
-
- The subject was standing, walking or running.
- Standing/upright
-
-
- It can be implied that the pulse is present if Rate >0 beats/min.
- Presence of a pulse or heart beat.
- Presence
-
-
- Details about the device used to measure the pulse rate or heart rate.
- Device
-
-
- Details about physical exertion being undertaken during the examination.
- Exertion
-
-
- For example, presence of a pacemaker, level of anxiety; pain or fever etc.
- Narrative description about any incidental factors that may affect interpretation of the physical findings.
- Confounding factors
-
-
- For example, auscultation or electronic monitoring.
- Method used to observe the pulse or heart beat.
- Method
-
-
- Narrative description about the pulse or heart beat.
- Clinical description
-
-
- Coding with a terminology is preferred, where possible. For example: Bradycardia, Extrasystoles or Sinus rhythm. Multiple statements are allowed.
- Single word, phrase or brief description that represents the clinical meaning and significance of the pulse or heart beat findings, including the rhythm.
- Clinical interpretation
-
-
- A pulse or heart beat can be detected.
- Present
-
-
- A pulse or heart beat cannot be detected.
- Not detected
-
-
- The pulse rate, measured in beats per minute.
- Pulse Rate
-
-
- The heart rate, measured in beats per minute.
- Heart Rate
-
-
- The pattern is irregular.
- Irregular
-
-
- Coding with a terminology is desired, where possible. For example: full, thready, bounding, slow rising, or collapsing. Multiple terms may be recorded.
- Description of the character of the pulse or heart beat.
- Character
-
-
- The findings are observed by physical touch of the observer on the subject.
- Palpation
-
-
- The findings are observed with the assistance of a device, such as a stethoscope.
- Auscultation
-
-
- The findings are observed non-invasively using a device such as a pulse oximeter or a stethoscope.
- Automatic, non-invasive
-
-
- Maximum pulse rate or heart rate observed during a period of exertion.
- Maximum
-
-
- Body site where the pulse or heart beat were observed.
- Body site
-
-
- The left radial artery.
- Radial Artery - Left
-
-
- The right radial artery.
- Radial Artery - Right
-
-
- The region of the heart.
- Heart
-
-
- The left carotid artery.
- Carotid Artery - Left
-
-
- The right carotid artery.
- Carotid Artery - Right
-
-
- The left femoral artery.
- Femoral Artery - Left
-
-
- The right femoral artery.
- Femoral Artery - Right
-
-
- Presence of a pulse.
- Pulse presence
-
-
- Presence of a heart beat.
- Heart beat presence
-
-
- An unspecified finger.
- Finger
-
-
- The left brachial artery.
- Brachial artery - Left
-
-
- The right brachial artery.
- Brachial artery - Right
-
-
- The findings are observed invasively using a device such as an arterial catheter.
- Automatic, invasive
-
-
- The lobe of an unspecified ear.
- Ear lobe
-
-
- An unspecified toe.
- Toe
-
-
- Selection of a value from this value set is only valid if 'Irregular' is selected from the 'Regularity' data element.
- More specific pattern of an irregular pulse or heart beat.
- Irregular type
-
-
- For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
- Additional information required to capture local content or to align with other reference models/formalisms.
- Extension
-
-
- Generic label to allow for any or all statements about the pulse or heart beat.
- Clinical interpretation
-
-
- Specific conclusion about the rhythm of the pulse or heartbeat, drawn from a combination of the heart rate, pattern and other characteristics observed on examination.
- Rhythm
-
-
- Additional narrative about the pulse or heart beat findings not captured in other fields.
- Comment
-
-
-
- OBSERVATION
-
- true
- false
- true
- 0
-
- at0000
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- HISTORY
-
- true
- true
- false
- false
- 1
- 1
-
- at0001
-
- events
-
- true
- true
- false
- false
- 0
- 1
-
-
- EVENT
-
- true
- false
- true
- 0
-
- at0006
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0003
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0004
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- openehr
-
- 125
-
-
-
- true
- false
- false
- false
- 0
- 1000
-
-
- true
- true
- false
- false
- 0
- 0
-
- mm[Hg]
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0005
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- openehr
-
- 125
-
-
-
- true
- false
- false
- false
- 0
- 1000
-
-
- true
- true
- false
- false
- 0
- 0
-
- mm[Hg]
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0033
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
- state
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0007
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0008
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- local
-
- at1001
-
-
- local
-
- at1000
- at1001
- at1002
- at1003
- at1014
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at1052
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- CLUSTER
-
- true
- true
- false
- false
- 0
- 1
-
- at1030
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at1043
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- local
-
- at1044
-
-
- local
-
- at1044
- at1045
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at1005
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- 0
- °
- 0
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-
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-
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-
-
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-
-
-
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-
-
-
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- value
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-
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-
-
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-
- at0015
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-
-
-
-
-
-
- CLUSTER
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- true
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- 0
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- items
-
- true
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- 1
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-
-
- ELEMENT
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- 0
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- value
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-
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- at0025
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-
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-
-
- C_STRING
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- openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
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- ELEMENT
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- openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
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- constraint
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-
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-
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-
-
-
-
-
-
- openEHR-EHR-OBSERVATION.blood_pressure.v1
-
-
- The local measurement of arterial blood pressure which is a surrogate for arterial pressure in the systemic circulation. Most commonly, use of the term 'blood pressure' refers to measurement of brachial artery pressure in the upper arm.
- Blood Pressure
-
-
- History Structural node.
- history
-
-
- @ internal @
- blood pressure
-
-
- Peak systemic arterial blood pressure - measured in systolic or contraction phase of the heart cycle.
- Systolic
-
-
- Minimum systemic arterial blood pressure - measured in the diastolic or relaxation phase of the heart cycle.
- Diastolic
-
-
- Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
- Any event
-
-
- @ internal @
- state structure
-
-
- The position of the subject at the time of measurement.
- Position
-
-
- List structure.
- Tree
-
-
- Perloff D, Grim C, Flack J, Frohlich ED, Hill M, McDonald M, Morgenstern BZ. Human blood pressure determination by sphygmomanometry. Circulation 1993;88;2460-2470.
- The size of the cuff used for blood pressure measurement.
- Cuff size
-
-
- Simple body site where blood pressure was measured.
- Location of measurement
-
-
- A cuff used for an adult thigh.
- Adult Thigh
-
-
- A cuff for adults with larger arms.
- Large Adult
-
-
- A cuff that is standard for an adult.
- Adult
-
-
- The right arm of the person.
- Right arm
-
-
- The left arm of the person.
- Left arm
-
-
- The right thigh of the person.
- Right thigh
-
-
- The left thigh of the person.
- Left thigh
-
-
- Additional narrative about the measurement, not captured in other fields.
- Comment
-
-
- Standing at the time of blood pressure measurement.
- Standing
-
-
- Sitting (for example on bed or chair) at the time of blood pressure measurement.
- Sitting
-
-
- Reclining at the time of blood pressure measurement.
- Reclining
-
-
- Lying flat at the time of blood pressure measurement.
- Lying
-
-
- PLEASE NOTE: '°' is a valid UCUM unit. Please use 'deg' as the correct unit.
- The craniocaudal tilt of the surface on which the person is lying at the time of measurement.
- Tilt
-
-
- The average arterial pressure that occurs over the entire course of the heart contraction and relaxation cycle.
- Mean arterial pressure
-
-
- The difference between the systolic and diastolic pressure.
- Pulse pressure
-
-
- A cuff used for a small adult.
- Small Adult
-
-
- A cuff that is appropriate for a child or adult with a thin arm.
- Paediatric/Child
-
-
- Record which Korotkoff sound is used for determining diastolic pressure using auscultative method.
- Diastolic endpoint
-
-
- The fourth Korotkoff sound is identified as an abrupt muffling of sounds.
- Phase IV
-
-
- The fifth Korotkoff sound is identified by absence of sounds as the cuff pressure drops below the diastolic blood pressure.
- Phase V
-
-
- Lying flat with some lateral tilt, usually angled towards the left side. Commonly required in the last trimester of pregnancy to relieve aortocaval compression.
- Lying with tilt to left
-
-
- A cuff used for infants.
- Infant
-
-
- A cuff used for a neonate, assuming cuff is the appropriate size for maturity and birthweight of the neonate.
- Neonatal
-
-
- The right wrist of the subject.
- Right wrist
-
-
- The left wrist of the subject.
- Left wrist
-
-
- Details about sphygmomanometer or other device used to measure the blood pressure.
- Device
-
-
- The right ankle of the subject.
- Right ankle
-
-
- Details about physical activity undertaken at the time of blood pressure measurement.
- Exertion
-
-
- The left ankle of the subject.
- Left ankle
-
-
- A finger of the subject.
- Finger
-
-
- Use 'Location of measurement' to select from a value set of common sites or free text choice. Use SLOT for 'Structured measurement location' to record unusual sites, such as intra-arterial catheter sites. 'Specific location' has been deprecated.
- Body location where blood pressure is measured.
- Location
-
-
- Data element deprecated, and replaced by free text component of 'Location of measurement' data type.
- X - Specific location
-
-
- Method of measurement of blood pressure.
- Method
-
-
- Method of measuring blood pressure externally, using a stethoscope and Korotkoff sounds.
- Auscultation
-
-
- Method of measuring blood pressure externally, using palpation (usually of the brachial or radial arteries).
- Palpation
-
-
- Formula used to calculate the Mean Arterial Pressure (if recorded in data).
- Mean arterial pressure formula
-
-
- Method of measuring blood pressure externally, using a blood pressure machine.
- Machine
-
-
- Method of measuring blood pressure internally ie involving penetration of the skin and measuring inside blood vessels.
- Invasive
-
-
- Estimate of the average blood pressure over a 24 hour period.
- 24 hour average
-
-
- Sleep status - supports interpretation of 24 hour ambulatory blood pressure records.
- Sleep status
-
-
- Subject is fully conscious.
- Alert & awake
-
-
- Subject is in the natural state of bodily rest.
- Sleeping
-
-
- A toe of the subject.
- Toe
-
-
- Comment on and record other incidental factors that may be contributing to the blood pressure measurement. For example, level of anxiety or 'white coat syndrome'; pain or fever; changes in atmospheric pressure etc.
- Confounding factors
-
-
- Invasive measurement via transducer access line within an artery.
- Intra-arterial
-
-
- Formula used to calculate the systolic pressure from from mean arterial pressure (if recorded in data).
- Systolic pressure formula
-
-
- Formula used to calculate the diastolic pressure from mean arterial pressure (if recorded in data).
- Diastolic pressure formula
-
-
- Structured anatomical location of where the measurement was taken.
- Structured measurement location
-
-
- For example: Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents.
- Additional information required to capture local context or to align with other reference models/formalisms.
- Extension
-
-
-
-
-
- SNOMED-CT(2003)
-
- 163020007
-
-
-
-
-
- SNOMED-CT(2003)
-
- 163030003
-
-
-
-
-
- SNOMED-CT(2003)
-
- 163031004
-
-
-
-
-
- SNOMED-CT(2003)
-
- 246153002
-
-
-
-
-
- OBSERVATION
-
- true
- false
- true
- 0
-
- at0000
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- data
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- events
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- EVENT
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-
- DV_QUANTITY
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- openehr
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- true
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- Cel
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-
- true
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- 30
- 200
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-
- true
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- [degF]
-
-
-
-
-
- ELEMENT
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- true
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- at0063
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- value
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- DV_TEXT
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-
-
-
-
-
- false
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- true
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-
-
-
-
-
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- state
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-
- ITEM_TREE
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- at0029
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- items
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- DV_COUNT
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- 1
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-
-
- magnitude
-
- true
- true
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- 1
-
-
- INTEGER
-
- true
- true
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- 1
-
-
-
-
- true
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-
-
-
-
-
-
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- CLUSTER
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- true
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- Boolean
- 2007
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- String
- archetype_id/value
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-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.environmental_conditions\.v1|openEHR-EHR-CLUSTER\.environmental_conditions\.v0|openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
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- constraint
-
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- CLUSTER
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- at0057
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- Boolean
- 2007
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- String
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-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.level_of_exertion\.v1|openEHR-EHR-CLUSTER\.level_of_exertion\.v0
-
- constraint
-
-
-
-
-
- true
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- true
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-
-
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-
-
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- protocol
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- true
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-
- ITEM_TREE
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- at0020
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- items
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- true
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- ELEMENT
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- at0021
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- value
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- true
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- 1
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-
- DV_CODED_TEXT
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- true
- true
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- 1
- 1
-
-
-
- defining_code
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- true
- true
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- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
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- 1
- 1
-
-
-
- local
-
- at0025
- at0024
- at0023
- at0061
- at0022
- at0026
- at0027
- at0028
- at0043
- at0051
- at0054
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-
-
-
- DV_TEXT
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-
-
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- CLUSTER
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- true
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- at0064
-
-
- Boolean
- 2007
- false
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- String
- archetype_id/value
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-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- CLUSTER
-
- true
- true
- false
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- 0
- 1
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- at0059
-
-
- Boolean
- 2007
- false
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- String
- archetype_id/value
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-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.device\.v1
-
- constraint
-
-
-
-
-
- CLUSTER
-
- true
- false
- true
- 0
-
- at0062
-
-
- Boolean
- 2007
- false
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- String
- archetype_id/value
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-
-
- C_STRING
-
- .*
-
- constraint
-
-
-
-
-
- true
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
- openEHR-EHR-OBSERVATION.body_temperature.v2
-
-
- A measurement of the body temperature, which is a surrogate for the core body temperature of the individual.
- Body temperature
-
-
- @ internal @
- Tree
-
-
- @ internal @
- History
-
-
- Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
- Any event
-
-
- The measured body temperature (as a surrogate for the core of the body).
- Temperature
-
-
- @ internal @
- Protocol
-
-
- The anatomical site of measurement of the temperature.
- Location of measurement
-
-
- Temperature is measured within the mouth.
- Mouth
-
-
- Temperature is measured from within the external auditory canal.
- Ear canal
-
-
- Temperature is measured from the skin of the axilla with the arm positioned down by the side.
- Axilla
-
-
- Temperature measured within the rectum.
- Rectum
-
-
- Temperature is measured within the nasopharynx.
- Nasopharynx
-
-
- Temperature is measured in the urinary bladder.
- Urinary bladder
-
-
- Temperature is measured within the vascular system.
- Intravascular
-
-
- State information about the patient.
- State
-
-
- The degree of exposure of the individual at the time of measurement.
- Body exposure
-
-
- No clothing, bedding or covering.
- Naked
-
-
- The person is covered by a lesser amount of clothing or bedding than deemed appropriate for the environmental circumstances.
- Reduced clothing/bedding
-
-
- The person is covered by an amount of clothing or bedding deemed appropriate for the environmental circumstances.
- Appropriate clothing/bedding
-
-
- The person is covered by an increased amount of clothing or bedding than deemed appropriate for the environmental circumstances.
- Increased clothing/bedding
-
-
- Description of the conditions applied to the subject that might influence their measured body temperature.
- Description of thermal stress
-
-
- Temperature is measured from exposed skin.
- Skin
-
-
- Temperature is measured within the vagina.
- Vagina
-
-
- Temperatue is measured within the oesophagus.
- Oesophagus
-
-
- Temperature is measured in the inguinal skin crease between the leg and abdominal wall.
- Inguinal skin crease
-
-
- Details about the environmental conditions at the time of temperature measurement.
- Environmental conditions
-
-
- Details about the exertion of the person at the time of temperature measurement.
- Exertion
-
-
- Details about the device use to measure body temperature.
- Device
-
-
- Temperature is measured at the temple, over the superficial temporal artery.
- Temple
-
-
- Temperature is measured on the forehead.
- Forehead
-
-
- e.g. Local information requirements or additional metadata to align with FHIR or CIMI equivalents.
- Additional information required to capture local content or to align with other reference models/formalisms.
- Extension
-
-
- Additional comment about the body temperature measurement not captured in other fields.
- Comment
-
-
- Structured anatomical location of where the measurement was taken.
- Structured measurement location
-
-
- Number of days since onset of last normal menstrual period.
- Current day of menstrual cycle
-
-
-
-
-
- LNC205
-
- 8310-5
-
-
-
-
-
- OBSERVATION
-
- true
- false
- true
- 0
-
- at0000
-
- data
-
- true
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- 1
-
-
- HISTORY
-
- true
- true
- false
- false
- 1
- 1
-
- at0002
-
- events
-
- true
- true
- false
- false
- 0
- 1
-
-
- EVENT
-
- true
- false
- true
- 0
-
- at0003
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0001
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 1
- 1
-
- at0004
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- openehr
-
- 124
-
-
-
- true
- true
- false
- false
- 0
- 1000
-
- kg
-
-
-
- true
- true
- false
- false
- 0
- 2000
-
- lb
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0024
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 1
-
-
-
-
-
-
- state
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0008
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0009
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- local
-
- at0011
-
-
- local
-
- at0011
- at0013
- at0010
- at0017
-
-
-
-
-
-
- ELEMENT
-
- true
- false
- true
- 0
-
- at0025
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- true
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 1
-
-
-
-
-
-
- protocol
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0015
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- CLUSTER
-
- true
- true
- false
- false
- 0
- 1
-
- at0020
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- true
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
- openEHR-EHR-OBSERVATION.body_weight.v1
-
-
- Measurement of the body weight of an individual.
- Body weight
-
-
- @ internal @
- Simple
-
-
- @ internal @
- history
-
-
- Any event.
- Any event
-
-
- The weight of the individual.
- Weight
-
-
- @ internal @
- state structure
-
-
- Description of the state of dress of the person at the time of weighing.
- State of Dress
-
-
- Clothing which may add significantly to weight, including shoes.
- Fully clothed, including shoes
-
-
- Clothing which will not add to weight significantly.
- Lightly clothed/underwear
-
-
- Without any clothes.
- Naked
-
-
- @ internal @
- protocol structure
-
-
- Wearing only a nappy - can add significant weight.
- Nappy/diaper
-
-
- Details about the weighing device.
- Device
-
-
- Comment about the measurement of weight.
- Comment
-
-
- Record any issues or factors that may impact on the measurement of body weight eg timing in menstrual cycle, timing of recent bowel motion or noting of amputation.
- Confounding Factors
-
-
-
- OBSERVATION
-
- true
- false
- true
- 0
-
- at0000
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- HISTORY
-
- true
- true
- false
- false
- 1
- 1
-
- at0001
-
- events
-
- true
- true
- false
- false
- 0
- 1
-
-
- EVENT
-
- true
- false
- true
- 1
-
- at0002
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0003
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 1
- 1
-
- at0004
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- openehr
-
- 122
-
-
-
- true
- true
- false
- false
- 0
- 1000
-
- cm
-
-
-
- true
- true
- false
- false
- 0
- 250
-
- in
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0018
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 1
-
-
-
-
-
-
- state
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0013
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0014
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- local
-
- at0016
-
-
- local
-
- at0016
- at0020
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0019
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 1
-
-
-
-
-
-
- protocol
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0007
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- CLUSTER
-
- true
- true
- false
- false
- 0
- 1
-
- at0011
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- true
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
- openEHR-EHR-OBSERVATION.height.v1
-
-
- Height, or body length, is measured from crown of head to sole of foot. Height is measured with the individual in a standing position and body length in a recumbent position.
- Height/Length
-
-
- @ internal @
- history
-
-
- Any timed measurement of height or body length.
- Any event
-
-
- @ internal @
- Simple
-
-
- The length of the body from crown of head to sole of foot.
- Height/Length
-
-
- @ internal @
- List
-
-
- Description of the device used to measure height or body length.
- Device
-
-
- @ internal @
- Tree
-
-
- Position of individual when measured.
- Position
-
-
- Height is measured standing on both feet with weight distributed evenly, heels together and both buttocks and heels in contact with a vertical back board.
- Standing
-
-
- Comment about the measurement of body height/length.
- Comment
-
-
- Record any issues or factors that may impact on the measurement of body height/length eg noting of amputation.
- Confounding factors
-
-
- Length is measured in a fully extended, recumbent position with the pelvis flat, legs extended and feet flexed.
- Lying
-
-
-
- OBSERVATION
-
- true
- false
- true
- 0
-
- at0000
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- HISTORY
-
- true
- true
- false
- false
- 1
- 1
-
- at0001
-
- events
-
- true
- true
- false
- false
- 0
- 1
-
-
- EVENT
-
- true
- false
- true
- 0
-
- at0002
-
- data
-
- true
- true
- false
- false
- 1
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0003
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0006
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_PROPORTION
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- numerator
-
- true
- true
- false
- false
- 1
- 1
-
-
- REAL
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- true
- true
- false
- false
- 0
- 100
-
-
-
-
-
- type
-
- true
- true
- false
- false
- 1
- 1
-
-
- INTEGER
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- 2
-
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0044
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- openehr
-
- 119
-
-
-
- true
- false
- true
- 0
-
- ml/ml
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0045
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_PROPORTION
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- numerator
-
- true
- true
- false
- false
- 1
- 1
-
-
- REAL
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- true
- true
- false
- false
- 0
- 100
-
-
-
-
-
- is_integral
-
- true
- true
- false
- false
- 1
- 1
-
-
- BOOLEAN
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- false
- true
-
-
-
-
- type
-
- true
- true
- false
- false
- 1
- 1
-
-
- INTEGER
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- 2
-
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0046
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_PROPORTION
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- numerator
-
- true
- true
- false
- false
- 1
- 1
-
-
- REAL
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- true
- true
- false
- false
- 0
- 100
-
-
-
-
-
- is_integral
-
- true
- true
- false
- false
- 1
- 1
-
-
- BOOLEAN
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- false
- true
-
-
-
-
- type
-
- true
- true
- false
- false
- 1
- 1
-
-
- INTEGER
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- 2
-
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0039
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- openehr
-
- 125
-
-
-
- true
- false
- true
- 0
-
-
- true
- true
- false
- false
- 1
- 1
-
- mm[Hg]
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0040
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- openehr
-
- 125
-
-
-
- true
- false
- true
- 0
-
-
- true
- true
- false
- false
- 1
- 1
-
- mm[Hg]
-
-
-
-
-
- CLUSTER
-
- true
- false
- true
- 0
-
- at0054
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- ELEMENT
-
- true
- false
- true
- 0
-
- at0019
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_MULTIMEDIA
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- media_type
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- IANA_media-types
-
-
-
-
-
-
-
- ELEMENT
-
- true
- false
- true
- 0
-
- at0058
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
- state
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0014
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- CLUSTER
-
- true
- true
- false
- false
- 0
- 1
-
- at0034
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- CLUSTER
-
- true
- true
- false
- false
- 0
- 1
-
- at0015
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v0
-
- constraint
-
-
-
-
-
- ELEMENT
-
- true
- false
- true
- 0
-
- at0016
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 1
-
-
-
-
-
-
- protocol
-
- true
- true
- false
- false
- 0
- 1
-
-
- ITEM_TREE
-
- true
- true
- false
- false
- 1
- 1
-
- at0007
-
- items
-
- true
- true
- false
- false
- 0
- 1
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0009
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0020
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_CODED_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- defining_code
-
- true
- true
- false
- false
- 1
- 1
-
-
- CODE_PHRASE
-
- true
- true
- false
- false
- 1
- 1
-
-
-
- local
-
- at0048
- at0049
- at0050
- at0051
- at0052
-
-
-
-
- DV_TEXT
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0037
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_QUANTITY
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
- openehr
-
- 127
-
-
-
- true
- true
- false
- false
- 0
- 100
-
-
- true
- true
- false
- false
- 1
- 1
-
- Cel
-
-
-
-
-
- ELEMENT
-
- true
- true
- false
- false
- 0
- 1
-
- at0038
-
- value
-
- true
- true
- false
- false
- 0
- 1
-
-
- DV_DATE_TIME
-
- true
- true
- false
- false
- 1
- 1
-
-
-
-
-
-
- CLUSTER
-
- true
- true
- false
- false
- 0
- 1
-
- at0018
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- CLUSTER
-
- true
- false
- true
- 0
-
- at0059
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- .*
-
- constraint
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
-
-
- openEHR-EHR-OBSERVATION.indirect_oximetry.v0
-
-
- Method of monitoring blood gas measurements such as Spo2 and spCO by indirect, currently non-invasive, means.
- Indirect oximetry
-
-
- @ internal @
- Event Series
-
-
- Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
- Any event
-
-
- @ internal @
- Tree
-
-
- spO2 is defined as the ratio of oxyhaemoglobin (HbO2) to the total concentration of haemoglobin (HbO2 + deoxyhaemoglobin).
- Measured via pulse oximetry, the saturation of oxygen in the peripheral blood.
- spO2
-
-
- @ internal @
- List
-
-
- The site of the measurement sensor.
- Sensor site
-
-
- @ internal @
- Tree
-
-
- Details of the amount of oxygen available to the subject at the time of observation. Assumed values of 21% oxygen concentration, Fi02 of 0.21 and oxygen flow rate of 0 l/min or 0 ml/min.
- Inspired oxygen
-
-
- Comment on and record other incidental factors that may be affect interpretation of the observation. For example, motion, pain, poor perfusion, infant feeding.
- Confounding factors
-
-
- Details of the non-invasive oximetry device used.
- Oximetry device
-
-
- Details of a series of oximetry readings, other than waveforms, expressed as a multimedia image or series of images. Waveforms should be recorded using the Waveform slot and associated cluster archetype.
- Multimedia image
-
-
- For example: transmittal electrode; reflective electrode; clamp electrode; or strip electrode.
- The type of measurement sensor used.
- Sensor type
-
-
- Details about physical activity undertaken at the time of measurement.
- Exertion
-
-
- A text comment about the indirect oximetry result.
- Comment
-
-
- The operating temperature of a transcutaneous oximeter electrode.
- Data element deprecated.
- X - Electrode operating temperature
-
-
- The date and time at which the sensor was applied. Significant for transcutaneous oximetry.
- Data element deprecated.
- X - Time of sensor application
-
-
- Measured via transcutaneous electrode oximetry, the partial pressure of oxygen in the peripheral blood.
- Data element deprecated.
- X - ptcO2
-
-
- Measured via transcutaneous electrode oximetry, the partial pressure of carbon dioxide in the peripheral blood.
- Data element deprecated.
- X - ptcCO2
-
-
- Measured via pulse CO-oximetry, the oxygen content of the peripheral blood.
- spOC
-
-
- Measured via pulse CO-oximetry, the saturation of carboxyhaemoglobin in the perpiheral blood.
- spCO
-
-
- Measured via pulse CO-oximetry, the saturation of methoxyhaemoglobin in the peripheral blood.
- spMet
-
-
- A pulse oximetry transmittal sensor was applied.
- Transmittal
-
-
- A pulse oximetry reflective sensor was applied.
- Reflective
-
-
- A pulse oximetry clamp sensor was applied.
- Clamp
-
-
- A pulse oximetry strip sensor was applied.
- Strip
-
-
- Value deprecated. (A transcutaneous electrode sensor was applied.)
- X - Electrode
-
-
- A waveform reading associated with the oximetry measurement.
- Waveform
-
-
- Coding with a terminology is preferred, if possible. For example, normal oxygen saturation or hypoxaemia.
- Single word, phrase or brief description represents the clinical meaning and significance of the physical examination findings.
- Interpretation
-
-
- e.g. Local hospital departmental infomation or additional metadata to align with HL7 or CDISC equivalents.
- Additional information required to capture local context or to align with other reference models/formalisms.
- Extension
-
-
-
-
-
- SNOMED-CT
-
- 252465000
-
-
-
-
-
- SNOMED-CT
-
- 431314004
-
-
-
-
-
- SNOMED-CT
-
- 16206004
-
-
-
-
-
- SNOMED-CT
-
- 448703006
-
-
-
-
-
- SNOMED-CT
-
- 277923006
-
-
-
-
-
-
-
- LOINC
-
- 59408-5
-
-
-
-
-
- LOINC
-
- 20081-6
-
-
-
-
-
- LOINC
-
- 33437-5
-
-
-
-
-
- LOINC
-
- 33022-5
-
-
-
-
-
- EVALUATION
-
- true
- true
- false
- false
- 0
- 1
-
- at0002
-
-
- Boolean
- 2007
- false
-
- String
- archetype_id/value
- attribute
-
-
- C_STRING
-
- openEHR-EHR-EVALUATION\.clinical_synopsis(-[a-zA-Z0-9_]+)*\.v1
-
- constraint
-
-
-
-
-
- false
- false
-
- true
- false
- true
- 1
-
-
-
-
- openEHR-EHR-SECTION.vital_signs.v0
-
-
- A group of observations that are recorded at the same time and record the blood pressure, pulse, temperature and other readings.
- Vital signs
-
-
- Vital signs observations.
- Vital signs
-
-
- Textual summary of vital signs.
- Synopsis
-
-
-
- false
- false
-
- true
- false
- true
- 0
-
-
-
-
- openEHR-EHR-COMPOSITION.health_summary.v1
-
-
- Vital_Signs_Summary.EN.v1
-
-
- Generic document containing a summary of health information about an individual.
- Health summary
-
-
- @ internal @
- Tree
-
-
- For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
- Additional information required to capture local content or to align with other reference models/formalisms.
- Extension
-
-
-
-
-
- true
-
-
-
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- true
-
-
-
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- true
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\ No newline at end of file
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/covid_19_pneumonia_diagnosis_and_treatment_7th_edition.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/covid_19_pneumonia_diagnosis_and_treatment_7th_edition.opt
new file mode 100644
index 000000000..76e3e4c42
--- /dev/null
+++ b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/covid_19_pneumonia_diagnosis_and_treatment_7th_edition.opt
@@ -0,0 +1,239 @@
+ISO_639-1enXudong LuZhejiang Universitylvxd@zju.edu.cn2020-04-07Heather Leslie<heather.leslie@atomicainformatics.com>Shan Nan<nanshan@zju.edu.cn>Mengyang Li<lmy_86263@zju.edu.cn>Hailing Cai<chl@vico-lab.com>Bin Qi<Qi.Bin@vico-lab.com>Tianhua Tang<11915018@zju.edu.cn>Hongshuo Feng<21915015@zju.edu.cn>InitialTemplate metadata sample set1a36be5935c97561ec3b9a57fb7289d5706E6DA39FA082EE75E0F0D4E4A87F25ISO_639-1enThe template is developed to promote interoperability among systems for the diagnosis and treatment of COVID-19. The data points included in the template were abstracted from the 7th version of Diagnosis and Treatment Guideline of COVID-19 released by the National Health Commission of the People's Republic of China (Printed and distributed on March 3, 2020), the translated English version can be found in https://www.chinalawtranslate.com/en/coronavirus-treatment-plan-7/.openEHRCOVID-19DiagnosisTreatmentCDSThere may be some differences in the guidelines issued by authorities from other countries. Therefore, the specific requirements and clinical environment of the country or region should be examined.abfc7f16-ad25-433c-b90a-eb15d89e60a8COVID-19 Pneumonia Diagnosis and Treatment (7th edition)COVID-19 Pneumonia Diagnosis and Treatment (7th edition)COMPOSITIONtruetruefalsefalse11at0000categorytruetruefalsefalse11DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11openehr433contexttruetruefalsefalse01EVENT_CONTEXTtruetruefalsefalse11other_contexttruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0002Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11COVID-19 Pneumonia Diagnosis and Treatment (7th edition)contenttruetruefalsefalse01SECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Clinical backgrounditemstruetruefalsefalse01OBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0004valuetruetruefalsefalse01DV_DURATIONtruetruefalsefalse11ELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_DURATIONtruetruefalsefalse11falsefalsetruefalsetrue0falsefalsetruefalsetrue1openEHR-EHR-OBSERVATION.age.v0Details about the age of an individual.Age@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeAge based on actual date of birth.Chronological ageAge based on due date.Adjusted ageFor example: pre-term deliveryAdditional narrative about the age of an individual, not captured in other fields.CommentOBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0034valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11S840544004ELEMENTtruetruefalsefalse01at0028valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0031at0032at0033nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Symptomatic/Asymptomatic?CLUSTERtruetruefalsefalse01at0022itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT386661006842290011183300568235000645310031623970036896200126703600762315008ELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0023at0024at0027CLUSTERtruefalsetrue0at0026Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Typical symptom/signCLUSTERtruetruefalsefalse01at0022itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT4224000082717820012142640039117500016183800234095006271825005304534000ELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0023at0024at0027CLUSTERtruefalsetrue0at0026Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Child specific symptom/signfalsefalsetruefalsetrue0falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0007itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0021Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-OBSERVATION.symptom_sign_screening.v0An individual- or self-reported questionnaire screening for symptoms and signs.Symptom/sign screening questionnaire@ internal @HistoryDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeName of the symptom or sign being screened.Symptom or sign namePresence of the symptom or sign.Presence?@ internal @Item treeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionGrouping of data elements related to screening for a single symptom or sign.Specific symptom/signThe specific symptom or sign is present.PresentThe specific symptom or sign is not present.AbsentAdditional narrative about the symptoms and signs, not captured in other fields.Overall commentAdditional structured details related to a specific symptom or sign.Symptom/sign detailsIt is not known whether the symptom or sign is present or absent.UnknownPresence of any relevant symptoms or signs.Presence of any symptoms or signs?Partial dates are allowed.The date/time when any symptoms or signs were first noticed.Onset of any symptoms or signsSymptoms or signs are present.PresentSymptoms or signs are not present.AbsentIt is not known whether any symptoms or signs are present or absent.UnknownFor example: screening for an infectious disease, such as SARS-COV-2.The reason for overall screening.Screening purposeAdditional narrative about the specific symptom or sign, not captured in other fields.CommentNarrative description about all symptoms or signs.DescriptionSuspected disease caused by SARS-CoV-2FeverFatigueDry coughNasal congestionNasal dischargeSore throatMuscle painShortness of breathDiarrheaVomitingDrowsinessLethargyConvulsionInfant feeding problemDehydrationDistressed breathingCryingSNOMED-CT410515003SNOMED-CT410516002SNOMED-CT261665006SNOMED-CT410515003SNOMED-CT410516002SNOMED-CT261665006OBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0022itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT38908700634150046778200576571007594550096477900827942005576530007738600639819200323453200165710008ELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0023at0024at0027CLUSTERtruefalsetrue0at0039Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.clinical_evidence\.v1constraintfalsefalsetruefalsetrue1ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_DURATIONtruetruefalsefalse11DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0036at0037at0038falsefalsetruefalsetrue0falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0007itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0021Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Condition/finding screening questionnaireopenEHR-EHR-OBSERVATION.condition_screening.v0An individual- or self-reported questionnaire screening for conditions, including problems, diagnoses and pregnancy.Condition screening questionnaire@ internal @HistoryDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeName of the condition being screened.Condition namePresence of the condition.Presence?Partial dates are allowed.The date/time when the condition was first noticed by the individual or diagnosed by a clinician.Onset@ internal @Item treeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionGrouping of data elements related to screening for a single condition.Specific conditionThe specific condition is present.PresentThe specific condition is not present.AbsentAdditional narrative about the conditions, not captured in other fields.Overall commentIt is not known whether the condition is present or absent.UnknownPresence of any relevant conditions.Presence of any conditions?Partial dates are allowed.The date/time when any conditions were first noticed.Pregnancy gestationConditions are present.PresentConditions are not present.AbsentIt is not known whether any conditions are present or absent.UnknownFor example: pre-operative screening.The reason for overall screening.Screening purposeAdditional narrative about the specific condition, not captured in other fields.CommentBetween first day of last period and the end of week 12.First trimesterBetween week 13 and week 28.Second trimesterAfter week 28.Third trimesterFor example: Clinical evidence or a disease specific grading scale.Additional details about the specific condition.Condition detailsHypoxemiaCyanosisAcute respiratory distress syndromeSeptic shockMetabolic acidosisBlood coagulation disorderShockMultiple organ failurePregnantComorbid conditionsImmunodeficiencyAcute respiratory failureSNOMED-CT410515003SNOMED-CT410516002SNOMED-CT261665006SNOMED-CT410515003SNOMED-CT410516002SNOMED-CT261665006OBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0022itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT40617009305351004ELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0023at0024at0027nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Carried out?CLUSTERtruefalsetrue0at0036Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.inspired_oxygen\.v1constraintfalsefalsetruefalsetrue1falsefalsetruefalsetrue0falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0007itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0021Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-OBSERVATION.management_screening.v0An individual- or self-reported questionnaire screening for management or treatment carried out.Management/treatment screening questionnaire@ internal @HistoryDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeName of the management or treatment activity being screened.Activity nameDid the management or treatment activity take place?Actioned?Partial dates are allowed.The date/time when the management or treatment activity was carried out.Date actioned@ internal @Item treeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionGrouping of data elements related to screening for a single management or treatment activity.Specific management/treatment activityThe specific management activity was carried out.ActionedThe specific management activity was not carried out.Not actionedAdditional narrative about all management and treatment activities, not captured in other fields.Overall commentIt is not known whether the management activity was carried out.UnknownFor example: screening for an infectious disease, such as SARS-COV-2.The reason for overall screening.Screening purposeAdditional narrative about the specific management or treatment activity, not captured in other fields.CommentFor example: Details about oxygen therapy.Additional details about the specific activity.Activity detailsMechanical ventilationAdmission to intensive care unitSNOMED-CT385652002SNOMED-CT385660001SNOMED-CT261665006SECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Vital signsitemstruetruefalsefalse01OBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0002eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0003datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11falsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0029itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0056Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.environmental_conditions\.v1|openEHR-EHR-CLUSTER\.environmental_conditions\.v0constraintCLUSTERtruetruefalsefalse01at0057Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.level_of_exertion\.v1|openEHR-EHR-CLUSTER\.level_of_exertion\.v0constrainttruefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Any point in time eventfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0020itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0064Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative\.v1constraintCLUSTERtruetruefalsefalse01at0059Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device\.v1constraintCLUSTERtruefalsetrue0at0062truefalsetruefalsetrue0openEHR-EHR-OBSERVATION.body_temperature.v2A measurement of the body temperature, which is a surrogate for the core body temperature of the individual.Body temperature@ internal @Tree@ internal @HistoryDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any eventThe measured temperature.Temperature@ internal @ProtocolSimple description about the site of measurement.Location of measurementTemperature is measured within the mouth.MouthTemperature is measured from within the external auditory canal.Ear canalTemperature is measured from the skin of the axilla with the arm positioned down by the side.AxillaTemperature measured within the rectum.RectumTemperature is measured within the nasopharynx.NasopharynxTemperature is measured in the urinary bladder.Urinary bladderTemperature is measured within the vascular system.IntravascularState information about the patient.StateThe degree of exposure of the individual at the time of measurement.Body exposureNo clothing, bedding or covering.NakedThe person is covered by a lesser amount of clothing or bedding than deemed appropriate for the environmental circumstances.Reduced clothing/beddingThe person is covered by an amount of clothing or bedding deemed appropriate for the environmental circumstances.Appropriate clothing/beddingThe person is covered by an increased amount of clothing or bedding than deemed appropriate for the environmental circumstances.Increased clothing/beddingNarrative description of the conditions applied to the subject that might influence their measured body temperature.Description of thermal stressTemperature is measured from exposed skin.SkinTemperature is measured within the vagina.VaginaTemperatue is measured within the oesophagus.OesophagusTemperature is measured in the inguinal skin crease between the leg and abdominal wall.Inguinal skin creaseDetails about the environmental conditions at the time of temperature measurement.Environmental conditionsDetails about the exertion of the person at the time of temperature measurement.ExertionDetails about the device used to measure body temperature.DeviceTemperature is measured at the temple, over the superficial temporal artery.TempleTemperature is measured on the forehead.ForeheadFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.ExtensionAdditional comment about the body temperature measurement not captured in other fields.CommentStructured details about the location of measurement.Structured measurement locationThe first day of menstruation is considered to be Day 1 of each menstrual cycle.Current day of the menstrual cycle.Day of menstrual cycleAdditional issues or factors that may impact on the measurement of body temperature, not captured in other fields.Confounding factorsLNC2058310-5SNOMED-CT386725007OBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0004valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11falsefalsetruefalsetrue0statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0022itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0055Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruetruefalsefalse01at0037Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Any point in time eventfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0057itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0058Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-OBSERVATION.respiration.v2The characteristics of spontaneous breathing by an individual.Respiration@ internal @historyDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @ListThe frequency of spontaneous breathing.RateThe regularity of spontaneous breathing.RegularityThe breathing pattern is regular.RegularThe breathing pattern is not regular.IrregularCoding with a terminology is preferred, where possible. For example: Normal breathing; Evidence of respiratory distress; Kussmaul's respiration; Cheyne-Stokes respiration; or Apnoeic episodes. Multiple statements are allowed.Single word, phrase or brief description which represents the clinical meaning and significance of the respiration findings.Clinical interpretationThe depth of spontaneous breathing.DepthNormal depth of breathing.NormalShallow depth of breathing.ShallowDeep breathing.Deep@ internal @ListFor example: noting respiratory distress, use of accessory muscles or intermittent apnoea; noting characteristics such as stridor, sighing, grunting, groaning, gasping.
+Conducting a full respiratory examination, then some of these findings might be more appropriately recorded as part of examination findings.A narrative description about the spontaneous breathing of the individual.Clinical descriptionVariable depth of breathing.VariableThe individual's level of exertion during, or just prior to, the observation.Details about physical exertion being undertaken during the examination.ExertionAssumed values of 21% oxygen concentration, Fi02 of 0.21 and oxygen flow rate of 0 l/min or 0 ml/min.Details of the amount of oxygen being delivered to the individual at the time of observation.Inspired oxygenFor example: level of anxiety, pain, feeding in infants, tracheostomy.Identification of any issues or incidental factors that may impact on interpretation of the observation.Confounding factors@ internal @TreeFor example: local information requirements or additional metadata to align with FHIR.Additional information required to capture local context or to align with other reference models/formalisms.ExtensionThis data element may be useful in extreme situations where a formal measurement of respiration rate is not possible. For example: a subject is unconscious and distant to the observer, such as trapped in a car or has fallen down a cliff. Presence of respiration can be implied if the 'Rate' >0 breaths/min.Observation of spontaneous respiration.PresenceRespiratory movements are observed.PresentRespiratory movements are not detected on observation.Not detectedThe body position of the individual during the observation.Body positionThe individual was standing, walking or running.Standing/uprightThe individual was sitting (for example, on a bed or chair).SittingThe individual was reclining at an approximate angle of 45 degrees, with the legs elevated to the level of the pelvis.RecliningThe individual was lying on their back.LyingAdditional narrative about the respirations, not captured in other fields.CommentThe individual was lying on their front.ProneOBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0006valuetruetruefalsefalse01DV_PROPORTIONtruetruefalsefalse11numeratortruetruefalsefalse11REALtruetruefalsefalse11truetruefalsefalse0100typetruetruefalsefalse11INTEGERtruetruefalsefalse112CLUSTERtruefalsetrue0at0054Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0060Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue0statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0014itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0034Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruetruefalsefalse01at0015Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0007itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0018Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0059Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-OBSERVATION.pulse_oximetry.v1Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry.Pulse oximetry@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeSpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood.The saturation of oxygen in the peripheral blood, measured via pulse oximetry.SpO₂@ internal @ListFor example: Right index finger, left earlobe. Coding with a terminology is preferred, if possible.The site of the measurement sensor.Sensor site@ internal @TreeAssumed values of 21% oxygen concentration, Fi0₂ of 0.21 and oxygen flow rate of 0 l/min or 0 ml/min.Details of the amount of oxygen available to the subject at the time of observation.Inspired oxygenFor example, motion, pain, poor perfusion, infant feeding, peripheral hypothermia, sedation.Comment on and record other incidental factors that may be affect interpretation of the observation.Confounding factorsDetails of the non-invasive oximetry device used.Oximetry deviceDetails about physical activity undertaken at the time of measurement.ExertionA text comment about the pulse oximetry result.CommentThe oxygen content of the peripheral blood, calculated based on pulse oximetry and pulse CO-oximetry.SpOCThe saturation of carboxyhaemoglobin in the peripheral blood, measured via pulse CO-oximetry.SpCOThe saturation of methaemoglobin in the peripheral blood, measured via pulse CO-oximetry.SpMetA waveform reading associated with the oximetry measurement.WaveformCoding with a terminology is preferred, if possible. For example, normal oxygen saturation or hypoxaemia.Single word, phrase or brief description which represents the clinical meaning and significance of the measurements.Interpretatione.g. Local hospital departmental infomation or additional metadata to align with HL7 or CDISC equivalents.Additional information required to capture local context or to align with other reference models/formalisms.ExtensionDetails of a series of oximetry readings, other than waveforms, expressed as a multimedia image or series of images. Waveforms should be recorded using the Waveform slot and associated cluster archetype.Multimedia imageSensor site relative to the ductus arteriosus in neonates, to determine whether the blood supply to limb of the sensor site is pre- or post-ductal in cases of patent ductus arteriosus.Pre/post-ductalThe sensor site is pre-ductal.Pre-ductalThe sensor site is post-ductal.Post-ductalUnable to assess whether the sensor site is pre- or post-ductal.IndeterminateSNOMED-CT431314004SNOMED-CT16206004SNOMED-CT448703006SNOMED-CT277923006LOINC59408-5LOINC20081-6LOINC57800-5LOINC86904-0LOINC2614-6falsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Laboratory testsitemstruetruefalsefalse01OBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC94500-6CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Nasopharyngeal secretionsSputumLower respiratory tract secretionsCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC94500-6ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT10828004720735008260385009CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceSARS coronavirus 2 RNAPositivePresumptive positiveNegativeCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintELEMENTtruetruefalsefalse01at0121valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11RT-PCRNext Generation SequencingCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11SARS coronavirus 2 RNAopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisSARS coronavirus 2 RNAOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC94503-0CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum or plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC94505-594506-3ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11mg/dlg/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceSARS coronavirus 2 Ab.IgGSARS coronavirus 2 Ab.IgMCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11SerologyopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisSARS coronavirus 2 Ab.IgG & IgM panelOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC57021-8CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11BloodCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT6690-2789-8718-74544-3787-2785-6786-4777-3731-0751-8742-7711-2704-7ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceLeukocytesErythrocytesHemoglobinHematocritErythrocyte mean corpuscular volumeErythrocyte mean corpuscular hemoglobinErythrocyte mean corpuscular hemoglobin concentrationPlateletsLymphocytesNeutrophilsMonocytesEosinophilsBasophilsCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Complete blood count & differentialopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisCBC W Auto Differential panelOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC24336-0CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11CLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2744-12019-82703-71960-41925-7ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequencepHpCO2pO2HCO3Base excessCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0052valuetruetruefalsefalse01DV_PROPORTIONtruetruefalsefalse11numeratortruetruefalsefalse11REALtruetruefalsefalse11truetruefalsefalse01typetruetruefalsefalse11INTEGERtruetruefalsefalse111CLUSTERtruefalsetrue0at0058Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.inspired_oxygen.v1The amount of oxygen being delivered, or to be delivered, to the patient given as a fraction, percentage or indirectly as a flow rate.Inspired oxygenFor example '5 l/min'.Oxygen flow rate given to an individual.Flow rateFor example: '0.28'.Fraction of oxygen in inspired air.FiO₂For example: '24 %'Percentage of oxygen in inspired air.Percent O₂Intended to capture only simple description / terms, for example: 'nasal prongs'. The 'Oxygen delivery detail' slot may be used for more detailed or complex recording.The method used to deliver the oxygen.Method of oxygen deliveryWhere 'On air' is set to true, Flow rate, FiO₂ and Percent O₂ should not be recorded. Conversely 'On air' should be omitted if Flow rate, FiO₂ or Percent O₂ are recorded.The patient is receiving air, equivalent to 21% O₂ or 0.21 FiO₂ and an oxygen flow rate of 0 litres per minute.On airFor example details of humidification or assisted ventilation.Further details of the method of oxygen delivery.Oxygen delivery detailfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Arterial blood gasesopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
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+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisGas panel - Arterial bloodOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC1988-5CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC1988-5ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11mg/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceC reactive proteinCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11C reactive proteinopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisC reactive proteinOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC26881-3CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC26881-3ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceInterleukin 6CLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Interleukin 6openEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisInterleukin 6OBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC24325-3CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2885-21751-71975-21968-76768-61920-81742-6ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceProtein [Mass/volume] in Serum or PlasmaAlbumin [Mass/volume] in Serum or PlasmaBilirubin.total [Mass/volume] in Serum or PlasmaBilirubin.direct [Mass/volume] in Serum or PlasmaAlkaline phosphatase [Enzymatic activity/volume] in Serum or PlasmaAspartate aminotransferase [Enzymatic activity/volume] in Serum or PlasmaAlanine aminotransferase [Enzymatic activity/volume] in Serum or PlasmaCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Liver function panelopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisLiver function panelOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2157-6CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2157-6ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11[iU]/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceCreatine kinaseCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Creatine kinaseopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisCreatine kinaseOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC6598-7CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC6598-7ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceTroponin T.cardiac [Mass/volume] in Serum or PlasmaCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11TroponinsopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisTroponin T.cardiac [Mass/volume] in Serum or PlasmaOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2639-3CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2639-3ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceMyoglobin [Mass/volume] in Serum or PlasmaCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11MyoglobinopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisMyoglobin [Mass/volume] in Serum or PlasmaOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC30341-2CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC30341-2ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceErythrocyte sedemination rateCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11ESRopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisErythrocyte sedemination rateOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC48067-3CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC48067-3ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceFibrin D-dimerCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Fibrin D-dimeropenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisFibrin D-dimerOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2524-7CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2524-7ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11[iU]/Lmmol/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceLactate [Moles/volume] in Serum or PlasmaCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruefalsetrue0at0101valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11falsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11LactateopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisLactate [Moles/volume] in Serum or PlasmaOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2532-0CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2532-0ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11[iU]/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceLactate dehydrogenase [Enzymatic activity/volume] in Serum or PlasmaCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Lactate dehydrogenaseopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisLactate dehydrogenase [Enzymatic activity/volume] in Serum or PlasmaOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC31682-5CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC31682-5ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11[iU]/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceProcalcitoninCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11ProcalcitoninopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisProcalcitoninOBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01POINT_EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0004valuetruetruefalsefalse01DV_PROPORTIONtruetruefalsefalse11typetruetruefalsefalse11INTEGERtruetruefalsefalse110falsefalsetruefalsetrue0falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0005itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0006Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-OBSERVATION.pf_ratio.v0Also known as the PF ration, Carrico index or Horowitz quotient.Ratio between the partial pressure of oxygen in blood (PaO2) and the fraction of oxygen in the inhaled air (FiO2).PaO2/FiO2 ratio@ internal @HistoryDefault, unspecified point in time event which may be explicitly defined in a template or at run-time.Any point in time event@ internal @TreeCalculated ration value.PaO2/FiO2 ratio@ internal @Item treeFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.Extensionfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Imaging testsitemstruetruefalsefalse01OBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT399208008CLUSTERtruefalsetrue0at0006Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Pleural effusionConsolidationPatchy shadowsInterstitial changesInfiltrationCLUSTERtruefalsetrue0at0034Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location\.v1constraintELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0035at0036at0037CLUSTERtruefalsetrue0at0014falsefalsetruefalsetrue1openEHR-EHR-CLUSTER.imaging_finding.v0A single finding in an imaging examination.Imaging findingFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The presence or absence of the finding.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Presence?Additional narrative about the finding, not captured in other fields.Observation.noteNTE.3CommentAdditional structured detail about the finding.Structured detailCoding with an external terminology is strongly recommended.The name of the finding.Observation.codeOBX.3Finding nameNarrative description about the observed clinical finding.DescriptionNarrative description about the difference between a previous finding and the finding in this report.Comparison to previousThe finding is improving compared to previous imaging examinations.ImprovingThe finding is unchanged compared to previous imaging examinations.UnchangedThe finding is worsening compared to previous imaging examinations.WorseningSimple description of anatomical location.Anatomical locationStructured details about the location of the finding.Structured anatomical locationThe finding is observed in the image.PresentThe finding is not observed in the image.AbsentIt is not possible to determine if the finding is present or absent.IndeterminateELEMENTtruetruefalsefalse01at0020valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11No obvious signs of pneumoniaPresenting with pneumoniaCLUSTERtruefalsetrue0at0045Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0047itemstruetruefalsefalse01falsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11BaselineEVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT399208008CLUSTERtruefalsetrue0at0006Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Pleural effusionConsolidationPatchy shadowsInterstitial changesInfiltrationCLUSTERtruefalsetrue0at0034Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location\.v1constraintELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0035at0036at0037CLUSTERtruefalsetrue0at0014ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11ImprovingUnchangedWorseningfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.imaging_finding.v0A single finding in an imaging examination.Imaging findingFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The presence or absence of the finding.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Presence?Additional narrative about the finding, not captured in other fields.Observation.noteNTE.3CommentAdditional structured detail about the finding.Structured detailCoding with an external terminology is strongly recommended.The name of the finding.Observation.codeOBX.3Finding nameNarrative description about the observed clinical finding.DescriptionNarrative description about the difference between a previous finding and the finding in this report.Comparison to previousThe finding is improving compared to previous imaging examinations.ImprovingThe finding is unchanged compared to previous imaging examinations.UnchangedThe finding is worsening compared to previous imaging examinations.WorseningSimple description of anatomical location.Anatomical locationStructured details about the location of the finding.Structured anatomical locationThe finding is observed in the image.PresentThe finding is not observed in the image.AbsentIt is not possible to determine if the finding is present or absent.IndeterminateELEMENTtruetruefalsefalse01at0020valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11No obvious signs of pneumoniaPresenting with pneumoniaCLUSTERtruefalsetrue0at0045Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0047itemstruetruefalsefalse01falsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Follow upfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0025itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0041Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0026Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0046Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Chest x-rayopenEHR-EHR-OBSERVATION.imaging_exam_result.v0Record the findings and interpretation of an imaging examination performed.Imaging examination result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeCoding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex.The name of the imaging examination or procedure performed.Test nameAlso known as 'Examination type'. For example: Ultrasound; Computed tomography; or X-ray. Coding with a terminology is desirable, where possible. If the modality is specified by a code in the Examination result name, then this field may be redundant.Type of equipment that originally acquired the image or series of images.ModalityIdentification of the anatomical site related to a specific finding will be recorded within each instance of CLUSTER.imaging_finding.Structured detail about the anatomical site related to the entire result.Structured anatomical siteThe status of the examination result as a whole.Overall result statusNarrative description of the clinical findings.FindingsNo result yet available.RegisteredThis is an initial or interim result: data may be missing or verification not been performed.InterimThe result is complete and verified by the responsible radiologist.FinalThe result has been modified subsequent to being Final, and is complete and verified by the radiologist.AmendedThe result is not available because the examination was not started or completed.Cancelled / AbortedThis may include a link to the clinical information provided in the original examination request. If other sources of clinical information have been used, this should be clearly stated using this data element.Description of clinical information available at the time of interpretation of results.Clinical information providedThis data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result.Single word, phrase or brief description representing the likely condition or diagnosis.Imaging diagnosisAlso referred to as 'Opinion' or 'Impression'.Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate.ConclusionFor example: a note that the film was given to the patient.Additional narrative about the examination not captured in other fields.CommentThe date and/or time that the result was issued for the recorded 'Examination result status'.DateTime result issued@ internal @TreeDemographic details about the receiving imaging service performing the imaging test.Receiving imaging serviceDetails concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype.Examination request detailsThe local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier.Requester order identifierIdentification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed.Examination requested nameDetails about the clinician or organisation requesting the imaging examination.RequesterThe local identifier assigned to the examination order by the order filler, usually by the Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number.Receiver order identifierUnique identifier of this study allocated by the imaging service.DICOM study identifierThe local identifier given to the imaging examination report.Report identifierImages referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images.Image detailsUnique identifier of this image allocated by the imaging service (often the DICOM image instance UID).Image identifierUnique identifier of this series allocated by the imaging service.DICOM series identifierThe name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible.ViewDescription of the subject of care's positon when the image was performed.PositionSpecific date/time the imaging examination was performed.Image DateTimeAn attached or referenced image of a current view.ImageAdditional structured details of technical details and procedure.Structured techniqueStructured details about each imaging finding.Imaging findingsDigital image or video representing the exam result.Image representationFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.Extension@ internal @TreeNarrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result.Confounding factorsFor example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media.Narrative description about the technical details and procedure.TechniqueDetails about the image being reported.Reported imageFor example: narrative description about progression/worsening of a condition. Structured comparison details will require representation in a separate CLUSTER archetype.Details about an image being compared to the image being reported.Comparison imageThis data element is redundant if the anatomical site is identified in the 'Test name'.Simple description about the physical place on, or in, the body that was imaged.Anatomical siteIf there is no availability of previous imaging and/or reports this should also be stated using this data element.Narrative descripition about the comparison of this image, or series of images, with previous similar examinations.Comparison with previousFor example: the nature of any limitations and their impact on interpretation.Narrative description about the quality of the examination.Imaging qualityThis data element has multiple occurrences to allow for more than one differential diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Imaging diagnosis' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in each Imaging examination result.Single word, phrase or brief description representing a possible condition or diagnosis.Imaging differential diagnosisThis data element has 0..* occurrences to allow for more than one recommendation and associated rationale. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request.Suggestion for further imaging, investigations and/or referral, and associated rationale.RecommendationPlain chest x-rayOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT169069000CLUSTERtruefalsetrue0at0006Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Pleural effusionConsolidationPatchy shadowsInterstitial changesInfiltrationGround glass opacitiesCLUSTERtruefalsetrue0at0034Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location\.v1constraintELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0035at0036at0037CLUSTERtruefalsetrue0at0014falsefalsetruefalsetrue1openEHR-EHR-CLUSTER.imaging_finding.v0A single finding in an imaging examination.Imaging findingFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The presence or absence of the finding.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Presence?Additional narrative about the finding, not captured in other fields.Observation.noteNTE.3CommentAdditional structured detail about the finding.Structured detailCoding with an external terminology is strongly recommended.The name of the finding.Observation.codeOBX.3Finding nameNarrative description about the observed clinical finding.DescriptionNarrative description about the difference between a previous finding and the finding in this report.Comparison to previousThe finding is improving compared to previous imaging examinations.ImprovingThe finding is unchanged compared to previous imaging examinations.UnchangedThe finding is worsening compared to previous imaging examinations.WorseningSimple description of anatomical location.Anatomical locationStructured details about the location of the finding.Structured anatomical locationThe finding is observed in the image.PresentThe finding is not observed in the image.AbsentIt is not possible to determine if the finding is present or absent.IndeterminateELEMENTtruefalsetrue0at0020valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11No obvious signs of pneumoniaPresenting with pneumoniaCLUSTERtruefalsetrue0at0045Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0047itemstruetruefalsefalse01falsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11BaselineEVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT169069000CLUSTERtruefalsetrue0at0006Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Pleural effusionConsolidationPatchy shadowsInterstitial changesInfiltrationGround glass opacitiesCLUSTERtruefalsetrue0at0034Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location\.v1constraintELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0035at0036at0037CLUSTERtruefalsetrue0at0014ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11ImprovingUnchangedWorseningfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.imaging_finding.v0A single finding in an imaging examination.Imaging findingFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The presence or absence of the finding.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Presence?Additional narrative about the finding, not captured in other fields.Observation.noteNTE.3CommentAdditional structured detail about the finding.Structured detailCoding with an external terminology is strongly recommended.The name of the finding.Observation.codeOBX.3Finding nameNarrative description about the observed clinical finding.DescriptionNarrative description about the difference between a previous finding and the finding in this report.Comparison to previousThe finding is improving compared to previous imaging examinations.ImprovingThe finding is unchanged compared to previous imaging examinations.UnchangedThe finding is worsening compared to previous imaging examinations.WorseningSimple description of anatomical location.Anatomical locationStructured details about the location of the finding.Structured anatomical locationThe finding is observed in the image.PresentThe finding is not observed in the image.AbsentIt is not possible to determine if the finding is present or absent.IndeterminateELEMENTtruefalsetrue0at0020valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11No obvious signs of pneumoniaPresenting with pneumoniaCLUSTERtruefalsetrue0at0045Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0047itemstruetruefalsefalse01falsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Follow upfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0025itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0041Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0026Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0046Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11CT ChestopenEHR-EHR-OBSERVATION.imaging_exam_result.v0Record the findings and interpretation of an imaging examination performed.Imaging examination result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeCoding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex.The name of the imaging examination or procedure performed.Test nameAlso known as 'Examination type'. For example: Ultrasound; Computed tomography; or X-ray. Coding with a terminology is desirable, where possible. If the modality is specified by a code in the Examination result name, then this field may be redundant.Type of equipment that originally acquired the image or series of images.ModalityIdentification of the anatomical site related to a specific finding will be recorded within each instance of CLUSTER.imaging_finding.Structured detail about the anatomical site related to the entire result.Structured anatomical siteThe status of the examination result as a whole.Overall result statusNarrative description of the clinical findings.FindingsNo result yet available.RegisteredThis is an initial or interim result: data may be missing or verification not been performed.InterimThe result is complete and verified by the responsible radiologist.FinalThe result has been modified subsequent to being Final, and is complete and verified by the radiologist.AmendedThe result is not available because the examination was not started or completed.Cancelled / AbortedThis may include a link to the clinical information provided in the original examination request. If other sources of clinical information have been used, this should be clearly stated using this data element.Description of clinical information available at the time of interpretation of results.Clinical information providedThis data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result.Single word, phrase or brief description representing the likely condition or diagnosis.Imaging diagnosisAlso referred to as 'Opinion' or 'Impression'.Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate.ConclusionFor example: a note that the film was given to the patient.Additional narrative about the examination not captured in other fields.CommentThe date and/or time that the result was issued for the recorded 'Examination result status'.DateTime result issued@ internal @TreeDemographic details about the receiving imaging service performing the imaging test.Receiving imaging serviceDetails concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype.Examination request detailsThe local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier.Requester order identifierIdentification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed.Examination requested nameDetails about the clinician or organisation requesting the imaging examination.RequesterThe local identifier assigned to the examination order by the order filler, usually by the Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number.Receiver order identifierUnique identifier of this study allocated by the imaging service.DICOM study identifierThe local identifier given to the imaging examination report.Report identifierImages referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images.Image detailsUnique identifier of this image allocated by the imaging service (often the DICOM image instance UID).Image identifierUnique identifier of this series allocated by the imaging service.DICOM series identifierThe name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible.ViewDescription of the subject of care's positon when the image was performed.PositionSpecific date/time the imaging examination was performed.Image DateTimeAn attached or referenced image of a current view.ImageAdditional structured details of technical details and procedure.Structured techniqueStructured details about each imaging finding.Imaging findingsDigital image or video representing the exam result.Image representationFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.Extension@ internal @TreeNarrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result.Confounding factorsFor example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media.Narrative description about the technical details and procedure.TechniqueDetails about the image being reported.Reported imageFor example: narrative description about progression/worsening of a condition. Structured comparison details will require representation in a separate CLUSTER archetype.Details about an image being compared to the image being reported.Comparison imageThis data element is redundant if the anatomical site is identified in the 'Test name'.Simple description about the physical place on, or in, the body that was imaged.Anatomical siteIf there is no availability of previous imaging and/or reports this should also be stated using this data element.Narrative descripition about the comparison of this image, or series of images, with previous similar examinations.Comparison with previousFor example: the nature of any limitations and their impact on interpretation.Narrative description about the quality of the examination.Imaging qualityThis data element has multiple occurrences to allow for more than one differential diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Imaging diagnosis' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in each Imaging examination result.Single word, phrase or brief description representing a possible condition or diagnosis.Imaging differential diagnosisThis data element has 0..* occurrences to allow for more than one recommendation and associated rationale. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request.Suggestion for further imaging, investigations and/or referral, and associated rationale.RecommendationComputed tomography of chestfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Assessmentitemstruetruefalsefalse01OBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0042itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0043valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT840546002CLUSTERtruefalsetrue0at0044itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0045valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Travel to an at risk locationReside in an at risk locationContact with an infected personContact with an at risk personELEMENTtruetruefalsefalse01at0046valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0047at0048at0049CLUSTERtruefalsetrue0at0054Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.family_prevalence\.v1constraintfalsefalsetruefalsetrue1falsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Last 14 daysfalsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0056Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11COVID-19 exposure assessmentopenEHR-EHR-OBSERVATION.exposure_assessment.v0Details about actual or potential exposure to a chemical, physical or biological agent which has caused or may cause harm to an individual.Exposure assessment@ internal @HistoryDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Item tree@ internal @Item treeCoding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: 2019-nCoV; or HIV.The name of the chemical, physical or biological agent to which an individual may have been exposed.ExposureDetails about each possible exposure risk factor.Per risk factorFor example: Travel to an 'at risk' location; or exposure to infected body fluids. Coding of 'Risk factor' with a terminology is preferred, where possible.The name of the exposure risk factor.Risk factorPresence of the exposure risk factor.PresenceExposure risk has been identified for this individual.PresentIt is not possible to determine if the exposure risk is present or absent.IndeterminateExposure risk has not been identified for this individual.AbsentNarrative description about the exposure risk.DescriptionThe date/time that the exposure risk was identified.Date identifiedIdentification of the path to the archetype or data node for the evidence of exposure.Link to evidenceFor example: Prevalence of the risk factor in family members.Structured detail about other aspects of the exposure risk factor assessment.DetailAdditional narrative about the exposure risk factor not captured in other fields.CommentFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.ExtensionExposure to severe acute respiratory syndrome coronavirus 2EVALUATIONtruetruefalsefalse01at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0002valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT840539006CLUSTERtruetruefalsefalse01at0016itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0013valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Presentation with fever and/or respiratory symptomsImaging consistent with COVID-19 pneumoniaEarly levels of leukocytes or lymphocytes normal or decreasedRT-PCR positive for COVID-19Gene sequencing highly homologous with COVID-19IgM and IGM positive for COVID-19nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Clinical factorELEMENTtruetruefalsefalse01at0017valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0018at0026at0019CLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.family_prevalence\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Clinical manifestationtruefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0010itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11CLUSTERtruefalsetrue0at0011Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11COVID-19 clinical assessmentopenEHR-EHR-EVALUATION.health_risk.v1Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.Health risk assessment@ internal @structureCoding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.Health riskThere may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.Evaluation of the health risk.Risk assessmentDetails that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.Justification for this risk assessment.Rationale@ internal @TreeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionIdentification of the path to the archetype or data node for the evidence of risk.Link to evidenceFor example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of
+'Risk factor' with a terminology, where possible.Identification of the risk factor, by name.Risk factorNarrative description about the risk factor.DescriptionAdditional narrative about the risk assessment not captured in other fields.CommentDetails about each possible risk factor.Risk factorsPresence of the risk factor.PresenceThe risk factor has been identified for this individual.PresentThe risk factor has not been identified for this individual.AbsentRecord of whether the risk assessment is a relative or absolute.Assessment typeRatio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.Relative riskRatio of probability of a health event or condition occurring compared to the population as a whole.Absolute riskThat is: the risk of experiencing the identified 'Health risk' in the next <X> years.The time period during which the predicted health risk is relevant.Time periodThis data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician.The date this health risk assessment was last updated.Last updatedFor example: Framingham cardiovascular risk calculator.Identification of the algorithm or guideline used to make the assessment of risk.Assessment methodIt is not possible to determine if the risk factor is present or absent.IndeterminateFor example: Prevalence of the risk factor in family members.Structured detail about other aspects of the risk factor assessment.DetailRecord as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated.The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.MitigatedThe date/time that the risk factor was identified.Date identifiedAdditional narrative about the risk factor not captured in other fields.CommentDisease caused by severe acute respiratory syndrome coronavirus 2SNOMED-CT52101004SNOMED-CT2667000SNOMED-CT82334004EVALUATIONtruetruefalsefalse01at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0002valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Risk of severe or critical diseaseCLUSTERtruetruefalsefalse01at0016itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0013valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Progressive decrease in lympocytes.Progressive increase in inflammatory biomarkers, including IL-6 and CRP.Progressive increase in lactic acid.Rapid progression of lung lesions.ELEMENTtruetruefalsefalse01at0017valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0018at0026at0019CLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.family_prevalence\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Adult risk factorsCLUSTERtruetruefalsefalse01at0016itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0013valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Increase in respiratory ratePoor mental reaction and drowsiness.Progressive increase in lactic acid.Infiltration on both sides or in multiple lobes on chest x-ray.Pleural effusion on chest x-ray.Rapid progression of lung lesions on chest x-ray.Underlying diseases (for example congenital heart disease, bronchopulmonary dysplasia, respiratory tract deformity, abnormal hemoglobin and sever malnutrition etc)Underlying immunodeficiency.ELEMENTtruetruefalsefalse01at0017valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0018at0026at0019CLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.family_prevalence\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Child risk factorstruefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0010itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0011Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Risk of severe and critical diseaseopenEHR-EHR-EVALUATION.health_risk.v1Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.Health risk assessment@ internal @structureCoding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.Health riskThere may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.Evaluation of the health risk.Risk assessmentDetails that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.Justification for this risk assessment.Rationale@ internal @TreeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionIdentification of the path to the archetype or data node for the evidence of risk.Link to evidenceFor example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of
+'Risk factor' with a terminology, where possible.Identification of the risk factor, by name.Risk factorNarrative description about the risk factor.DescriptionAdditional narrative about the risk assessment not captured in other fields.CommentDetails about each possible risk factor.Risk factorsPresence of the risk factor.PresenceThe risk factor has been identified for this individual.PresentThe risk factor has not been identified for this individual.AbsentRecord of whether the risk assessment is a relative or absolute.Assessment typeRatio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.Relative riskRatio of probability of a health event or condition occurring compared to the population as a whole.Absolute riskThat is: the risk of experiencing the identified 'Health risk' in the next <X> years.The time period during which the predicted health risk is relevant.Time periodThis data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician.The date this health risk assessment was last updated.Last updatedFor example: Framingham cardiovascular risk calculator.Identification of the algorithm or guideline used to make the assessment of risk.Assessment methodIt is not possible to determine if the risk factor is present or absent.IndeterminateFor example: Prevalence of the risk factor in family members.Structured detail about other aspects of the risk factor assessment.DetailRecord as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated.The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.MitigatedThe date/time that the risk factor was identified.Date identifiedAdditional narrative about the risk factor not captured in other fields.CommentSNOMED-CT52101004SNOMED-CT2667000SNOMED-CT82334004EVALUATIONtruefalsetrue0at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01CLUSTERtruefalsetrue1at0003itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0007valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Upper respiratory tract infectionsCOVID-19 pneumoniaOther viral pneumoniaMycoplasma pneumoniaVasculitisDermatomyositisCryptogenic organising pneumoniaELEMENTtruetruefalsefalse01at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0015at0017DV_TEXTtruetruefalsefalse11CLUSTERtruefalsetrue0at0020Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.clinical_evidence\.v1constraintfalsefalsetruefalsetrue1truefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0018itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0019Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-EVALUATION.differential_diagnoses.v0A list of one or more possible conditions or diagnoses that may be responsible for the clinical presentation, examination findings and test results.Differential diagnoses@ internal @TreeDetails about a single differential diagnosis.Differential diagnosisLikelihood of this diagnosis being present.LikelihoodAdditional narrative about all differential diagnoses, not captured in other fields.CommentNarrative description about the rationale for this diagnosis being included as a differential.RationaleName of the differential diagnosis.DiagnosisPossibly the diagnosis, but without a weight of supportive evidence.SuspectedLikely to be the working diagnosis, with good supportive evidence.Likely@ internal @Item treeFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.ExtensionDetails about clinical evidence supporting a differential diagnosis.Clinical evidenceAdditional narrative about a single differential diagnosis, not captured in other fields.Overall commentfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Treatmentitemstruetruefalsefalse01INSTRUCTIONtruetruefalsefalse01at0000activitiestruetruefalsefalse01ACTIVITYtruefalsetrue1at0001descriptiontruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0009itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0121valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT17049700622531600130535100443014700838476000430449500470780800142731400228178900423357300842831100840617009124000038906600140898000076334006386639001723688009171022008CLUSTERtruefalsetrue0at0151Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.service_direction(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.therapeutic_direction\.v1constraintCLUSTERtruefalsetrue0at0132Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0149Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0116Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0008itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0141Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruetruefalsefalse01at0142Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0128Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.distribution\.v1constraintCLUSTERtruefalsetrue0at0112Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11TreatmentopenEHR-EHR-INSTRUCTION.therapeutic_activity_order.v0An order or instruction for a health-related therapy or activity to be carried out.Therapeutic activityCurrent Activity.Current Activity@ internal @Tree@ internal @TreeUsually equivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierUsually equivalent to the HL7 Filler Order Identifier.The local identifier assigned to the request by the clinician or organisation receiving the request for therapy.Receiver order identifierThis data element allows for recording of the timing for a single therapy, either as a date and time, a date ranges or a text descriptor which can allow for 'next available. In practice, clinicians will often think in terms of ordering therapys as approximate timing, for example: review in 3 months, 6 months or 12 months. As clinical systems need more exact parameters to operate on, this '3 months' will usually be converted to an exact date 3 months from the date of recording and stored using this data element. If complex timing or sequences of timings are required, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT and this data element becomes redundant.The date/time, or acceptable interval of date/time, for provision of the therapy.Activityy dueCoding of the 'Reason for order' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required.A short phrase describing the reason for the order.Reason for orderNarrative description about the reason for request.Reason descriptionCoding of the 'Intent' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required.Description of the intent for the order.IntentSpecific definitions of emergency and urgent will vary between clinical contexts, clinical systems and the nature of the request itself, so have not been defined in this archetype. If explicit timing is required then the Activity period should be clearly stated.Urgency of the order.UrgencyRecord as TRUE if additional information has been identified and will be forwarded when available. For example: pending test results.Supplementary information will be following the order.Supplementary informationDescription of the supplementary information.Information descriptionFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.ExtensionLanguage, transport or other personal requirements to support the patient's attendance or participation in carrying out the activity.Patient requirementsCoding of the 'Activity name' with a coding system is desirable, if available. For example: 'recommendation to rest in bed'; 'apply ice for 20 minutes every 2 hours'.The name of the single therapy or activity requested.Activity nameStatus is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. Coding with a terminology is preferred, where possible.The status of the order for the activity as indicated by the requester.Order statusDetails of additional clinicians, organisations or agencies who require copies of any communication.Distribution listAdditional detail about the activity ordered.Specific detailsThis data point should be used to describe the named activity in more detail, including how it should be delivered, individual concerns and issues that might be encountered in carrying out the activity.Narrative description about the activity ordered.DescriptionThe request requires immediate attention.EmergencyThe request requires prioritised attention.UrgentThe request does not require prioritised scheduling.RoutineDetails about the clinician or organisation requesting the therapy.RequesterDetails about the clinician or organisation receiving the request for therapy.ReceiverThis date/time is the equivalent to the latest possible date for carrying out the activity or to the date of expiry for this order. For example: an activity may be required to be completed before another event, such as scheduled surgery.The date/time that marks the conclusion of the clinically valid period of time for carrying out this activity.Activity period expiryThis date/time is the equivalent to the earliest possible date for carrying out the activity. For example: sometimes a certain amount of time must pass before an activity can be carried out. For example: 'start mobilisation 2 days post surgery'.The date/time that marks the beginning of the valid period of time for delivery of this activity.Activity period startRecord as TRUE to record explicity that the order has no expiry date. For example: required for a lifelong activity.The valid period for this order is open ended and has no date of expiry.Indefinite?Coding of the 'Activity type' with a coding system is desirable, if available. If the 'Therapy name' was coded, it is possible for this data point to be derived from the code. For example: 'Self-care intervention'.Category of therapy or activity ordered.Activity typeDigital document, image, video or diagram supplied as additional information to support or inform the order.Supporting informationAdditional narrative about the activity order not captured in other fields.CommentDetails about a complex order requiring a sequence of timings.Complex timingCoding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Sprained ankle' or 'Type 1 Diabetes mellitus'.The clinical reason for the ordered therapy.Clinical indicationIsolation because of infectionBedrestAdmission to intensive care unitFluid balance monitoringFeeding and dietry regimeVital signs monitoringOxygen therapy supportAntiviral therapyAntibiotic therapyExtracorporeal membrane oxygenationNon-invasive ventilationMechanical ventilationProne body positionCirculatory careRenal careImmunotherapyTermination of pregnancyTraditional Chinese Medicine therapyPsychological counsellingINSTRUCTIONtruetruefalsefalse01at0000activitiestruetruefalsefalse01ACTIVITYtruefalsetrue0at0001descriptiontruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0002itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0070valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT4575400938706700338689600938718800511659300353136009419933005444648007116648000CLUSTERtruetruefalsefalse01at0143Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.medication(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruefalsetrue0at0091valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11CLUSTERtruetruefalsefalse01at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0095Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0177Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.therapeutic_direction(-[a-zA-Z0-9_]+)*\.v1constraintBoolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintELEMENTtruefalsetrue0at0018valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11CLUSTERtruefalsetrue0at0069Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.medication_authorisation(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.medication_authorisation(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0166Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constrainttruefalsetruefalsetrue1falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0005itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0008Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Medication recommendationopenEHR-EHR-INSTRUCTION.medication_order.v2An order for a medication, vaccine, nutritional product or other therapeutic item for an identified individual.Medication orderDetails of the requested order.Order@ internal @TreeThis data element allows for multiple occurrences to be defined more explicitly at run-time, if required.Unique identifier for the medication order.Order identifierThe amount and units of the medication, vaccine or other therapeutic good to be used or administered at one time.Dose amount descriptionFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionThis narrative should normally subsume data captured in 'Dose amount', 'Dose timing' and any additional instructions for use. Where the medication dose directions are fully carried by the structured, computable dose directions, this element should carry the narrative equivalent, generally auto-generated. If it is not possible to represent the intended 'Dose direction' fully in computable form, partial representation is not recommended, and the directions should be only recorded in narrative form using this data element.Complete narrative description about how the ordered item is to be used.Overall directions descriptionFor example: 'Start if symptoms recur'. This is intended for a general pre-condition which should trigger the whole medication course to be started, and not for 'as required' administrations of an ongoing order.A condition which, when met, requires the commencement of administration or use.Order start criterionThe date and optional time to commence use of the ordered item.Order start date/timeThe date and optional time when it is planned to cease use of the ordered item.Order stop date/timeFor example: 'Stop after symptoms disappear''.A condition which, when met, requires the cessation of administration or use.Order stop criterionFor example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. It is not intended to carry an indication for administrative authorisation purposes.The clinical reason for use of the ordered item.Clinical indicationFor example: precautions as 'take with food', 'Avoid grapefruit', 'Dissolve in water', 'store in a cool, dry place'. This data element allows multiple occurrences and should be coded with a reference terminology, where possible.An additional instruction on how to use or store the ordered item.Additional instructionGenerally this is only used when passing information between legacy systems. For example: '10mg bd; 20mg n' as used by the NHS Dose syntax (in development).A parsable, computable text representation of the directions.Parsable directionsFor example: To record that the patient had been taking antibiotics 3 days prior to hospital admission, in the context of a 7 day course.The time period during which the individual/patient has already been using the ordered item as a part of the intended whole order but prior to the issuance of this order.Duration of order completedFor example: 'up to 1gram per day'. This cluster allows multiple occurrences to enable representation of multiple maximum doses that apply to different time periods. Lifetime maximum dose should not be carried here as it refers to multiple orders over time.Details about the maximum, cumulative dose allowed over a defined period for the ordered item.Maximum doseExample: 24 hours.The period of time during which the maximum dose is calculated.Allowed periodFor example: To record that the patient has taken the two first antibiotic tablets of a three day course, prior to discharge from the hospital to a nursing home.The number of administrations of the ordered item that have been completed, as part of the intended whole order but prior to the issuance of this order.Administrations completedDetails about medication safety for the ordered item.Medication safetyConfirmation by the prescriber that the normal dose or other safety limit has been overridden due to exceptional circumstances.Exceptional safety override?This SLOT allows for local variation in the different jurisdictions regarding medication dispensing amount to be managed.Details about the amount of the ordered item to be dispensed.Dispense amountFor example: details of repeat/refill supply. This SLOT allows for local variation in the different jurisdictions regarding medication authorisation and re-authorisation to be managed.Details of authorisation of the ordered item, including supporting local self-administration, issue and endorsement policies.Authorisation directionsDepending on the prescribing context this field could be used for either generic- or product-based prescribing. This data field can be used to record tightly bound orders of different medications when they are prescribed as a single pack. It is strongly recommended that the 'Medication item' be coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available.Name of the medication, vaccine or other therapeutic/prescribable item being ordered.Medication itemFor example: 'oral', 'intravenous', or 'topical'.
+Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.The route by which the ordered item is to be administered into the subject's body.RouteFor example: 'left upper arm', 'intravenous catheter right hand'.
+ Coding of the body site with a terminology is preferred, where possible.Name of the site of administration of the ordered item.Body siteStructured description of the site of administration of the ordered item.Structured body siteFor example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible.The technique or device by which the ordered item is to be administered.Administration methodDetails of the medical device used to assist administration of the ordered item.Administration deviceFor example: 'To reduce your blood pressure', 'To thin your blood'. This data element allows multiple occurrences and should be coded with a reference terminology, where possible. If required it is possible to use a LINK attribute to associate this element with, for example, the 'original diagnosis' in a separate Problem list composition but the indication should be explicitly recorded here, as the link target may change over time.An additional instruction directed primarily at the individual/patient or carers.Patient informationExample: Detailed instructions for phased dispensing of opiates.An additional instruction directed primarily at the person dispensing the ordered item.Dispense instructionFor example: 'Please check renal function in 2 weeks'. This data element allows multiple occurrences.An additional instruction which gives advice on recommended or required monitoring of the ordered item.Monitoring instructionCourse summary may be required when transmitting medication information between systems or representing a FHIR Medication statement. For example: as part of a referral, emergency patient summary or discharge communication.Summary information about use of the ordered item, such as current status or key dates, generally used in non-prescription contexts.Order summaryDetails about the whole medication order.Order detailsDirections about the dispensing of the ordered item.Dispense directionsFor example: 1, 1.5, 0.125.The maximum, cumulative amount of medication which should be administered within the allowed period. The unit for this amount is carried in Maximum amount unit.Maximum amountIn many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution.Permission for substitution with a bioequivalent item.Substitution directionFor example 'Urgent'. This is left to be templated or specialised according to local valuesets. Some jurisdictions allow instructions to dispense to be marked as 'urgent' so that the dispensary handles them quickly.An indicator of the urgency with which the ordered item should be dispensed.PriorityUse this SLOT where the detailed description of the ordered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients.Structured details about the overall preparation including strength, form and constituent substances.Preparation detailsFor example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible.The unit for the maximum amount allowed.Maximum amount unitFor example: 'pain relief'; 'palliative care'; 'low-dose prophylaxis'; 'rehydration'; 'nutritional infusion'.The overall therapeutic intent of the ordered item.Therapeutic intentThe total daily dose records the expected effective dose, and thus support titration of an initial low dose towards the effective dose over a period of time. This is not itself the target dose or goal but the actual effective daily dose against that goal. In some circumstances the Total daily dose will be calcuable from computable directions, in others it may need to be manually entered.Details about the total daily amount of the ordered item expected to be administered.Total daily effective doseFor example '20mg'.The amount of ordered item which will be taken each day if administered as intended.Total daily amountThe dose units are normally scientific units such as mg, ml rather than 'tablets'.The dose unit associated with the total daily amount.Total daily amount unitFor example 'Generic preparation not bio-equivalent'.The reason why an ordered item should not be substituted at dispense.Non-substitution reasonMay be used to control the time of dispensing of medications with potential for abuse. For example: benzodiazepines or analgesics.The date from which the ordered item is permitted to be dispensed for the first time.Dispensing start dateIn some jurisdictions, orders to dispense may have an expiry date after which the prescription may not be dispensed.The date after which the ordered item is no longer valid to be legally dispensed.Dispensing expiry dateFor example: 'Not responsive at maximum recommended dose. Critical situation.', 'Peniciilin is only valid treatment, likelihood of true penicillin allergy is low'.The reason for a clinical safety or maximum dose override.Override reasonFor example: 'Hypertension control', 'Target dose 20mg daily'. The description could be used to identify a name, phrase or paragraph about the purpose for recording total daily effective dose, commonly to allow to titration towards a specific target dose.
+The goal or target dose might be recorded here or more commonly as part of a linked EVALUATION 'Goal' archetype.Description of the reason for recording a total daily effective dose.PurposeAdditional structured details about the ordered item not captured in other fields.Additional detailsAdditional narrative about the medication order not captured in other fields.CommentSubstitution of the medication with a bioequivalent medication is allowed.PermittedSubstitution of the medication with a bioequivalent medication is not allowed.Not permittedThis SLOT allows for local variation in the different jurisdictions regarding medication dispensing.Further details related to dispense directions.Dispense detailsFor example: 'Allergic to penicillin', 'Atenolol duplicated'.A known or recognised safety issue which applies to this subject and the ordered item, such as an allergy, drug duplication warning or contraindication. This element is normally only recorded when this safety advice is overridden.Overriden safety adviceIn some settings, it is common to split overall narrative directions into more specific segments of narrative. For example in hospital settings, it can be common to split the overall directions into 'Dose amount' and 'Dose timing', both as narrative text. These terms can be applied at template or run-time.A narrative description of a specific part of overall directions.Specific directions descriptionFor example: 'Adjusted for amputation'.A description of the justification used to calculate a dose amount or administration rate where this is dependent on some other factor.Dosage justificationDetails of structured dose and timing directions.Structured dose and timing directionsOverriding of a known or recognised safety issue which applies to this subject and the ordered item, such as an allergy, drug duplication warning or contraindication.Safety overrideInterferon alfaLopinavirRitonavirRibavirinMethylprednisoloneChloroquine phosphateGlucocorticoidTocilizumabGamma globulinfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Dischargeitemstruetruefalsefalse01EVALUATIONtruetruefalsefalse01at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0002valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT428483004CLUSTERtruetruefalsefalse01at0016itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0013valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Body temperature normal for more than 3 daysRespiratory symptoms improvedChest x-ray shows absorption of inflammationNucleic acid tests negative on 2 consecutive samples, at least 24 hours apartnametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11FactorELEMENTtruetruefalsefalse01at0017valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0018at0026at0019CLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.family_prevalence\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Clinical factorsELEMENTtruetruefalsefalse01at0003valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Fit for dischargeNot fit for dischargenametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Discharge assessmenttruefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0010itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11CLUSTERtruefalsetrue0at0011Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Discharge criteriaopenEHR-EHR-EVALUATION.health_risk.v1Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.Health risk assessment@ internal @structureCoding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.Health riskThere may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.Evaluation of the health risk.Risk assessmentDetails that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.Justification for this risk assessment.Rationale@ internal @TreeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionIdentification of the path to the archetype or data node for the evidence of risk.Link to evidenceFor example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of
+'Risk factor' with a terminology, where possible.Identification of the risk factor, by name.Risk factorNarrative description about the risk factor.DescriptionAdditional narrative about the risk assessment not captured in other fields.CommentDetails about each possible risk factor.Risk factorsPresence of the risk factor.PresenceThe risk factor has been identified for this individual.PresentThe risk factor has not been identified for this individual.AbsentRecord of whether the risk assessment is a relative or absolute.Assessment typeRatio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.Relative riskRatio of probability of a health event or condition occurring compared to the population as a whole.Absolute riskThat is: the risk of experiencing the identified 'Health risk' in the next <X> years.The time period during which the predicted health risk is relevant.Time periodThis data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician.The date this health risk assessment was last updated.Last updatedFor example: Framingham cardiovascular risk calculator.Identification of the algorithm or guideline used to make the assessment of risk.Assessment methodIt is not possible to determine if the risk factor is present or absent.IndeterminateFor example: Prevalence of the risk factor in family members.Structured detail about other aspects of the risk factor assessment.DetailRecord as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated.The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.MitigatedThe date/time that the risk factor was identified.Date identifiedAdditional narrative about the risk factor not captured in other fields.CommentMedically fit for dischargeSNOMED-CT52101004SNOMED-CT2667000SNOMED-CT82334004falsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Conclusionitemstruetruefalsefalse01EVALUATIONtruetruefalsefalse01at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0002valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED_CT882784691000119100674814021000119106880529761000119102138389411000119105866151004866152006CLUSTERtruefalsetrue0at0039Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11MildModerateSevereCriticalCLUSTERtruefalsetrue0at0043Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0046Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0032itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0070valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11COVID-19 diagnosisopenEHR-EHR-EVALUATION.problem_diagnosis.v1Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.Problem/Diagnosis@ internal @structureCoding of the name of the problem or diagnosis with a terminology is preferred, where possible.Identification of the problem or diagnosis, by name.Problem/Diagnosis namePartial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.Date/time clinically recognisedIf severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.An assessment of the overall severity of the problem or diagnosis.SeverityUse to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.Narrative description about the problem or diagnosis.Clinical descriptionCoding of the name of the anatomical location with a terminology is preferred, where possible.
+Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.Identification of a simple body site for the location of the problem or diagnosis.Body sitePartial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.Date/time of resolution@ internal @TreeUse this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations.
+
+If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.A structured anatomical location for the problem or diagnosis.Structured body siteMay include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.Details that are additionally required to record as unique attributes of this problem or diagnosis.Specific detailsUse status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.StatusThe problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.MildThe problem or diagnosis causes interference with normal activity or will damage health if left untreated.ModerateThe problem or diagnosis prevents normal activity or will seriously damage health if left untreated.SevereAdditional narrative about the problem or diagnosis not captured in other fields.CommentThe date this problem or diagnosis was last updated.Last updatedFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionNarrative description about the course of the problem or diagnosis since onset.Course descriptionThe level of confidence in the identification of the diagnosis.Diagnostic certaintyThe diagnosis has been identified with a low level of certainty.SuspectedThe diagnosis has been identified with a high level of certainty.ProbableThe diagnosis has been confirmed against recognised criteria.ConfirmedData captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.Date/time of onsetPneumonia caused by SARS-CoV-2Acute respiratory distress syndrome caused by SARS-CoV-2Lower respiratory infection caused by SARS-CoV-2Acute bronchitis caused by SARS-CoV-2Lymphocytopenia associated with severe acute respiratory syndrome coronavirus 2Thrombocytopenia associated with severe acute respiratory syndrome coronavirus 2EVALUATIONtruetruefalsefalse01at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0002valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11CLUSTERtruefalsetrue0at0039Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0047at0048at0049DV_TEXTtruetruefalsefalse11CLUSTERtruefalsetrue0at0043Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0046Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0032itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0070valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Other diagnosisopenEHR-EHR-EVALUATION.problem_diagnosis.v1Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.Problem/Diagnosis@ internal @structureCoding of the name of the problem or diagnosis with a terminology is preferred, where possible.Identification of the problem or diagnosis, by name.Problem/Diagnosis namePartial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.Date/time clinically recognisedIf severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.An assessment of the overall severity of the problem or diagnosis.SeverityUse to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.Narrative description about the problem or diagnosis.Clinical descriptionCoding of the name of the anatomical location with a terminology is preferred, where possible.
+Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.Identification of a simple body site for the location of the problem or diagnosis.Body sitePartial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.Date/time of resolution@ internal @TreeUse this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations.
+
+If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.A structured anatomical location for the problem or diagnosis.Structured body siteMay include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.Details that are additionally required to record as unique attributes of this problem or diagnosis.Specific detailsUse status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.StatusThe problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.MildThe problem or diagnosis causes interference with normal activity or will damage health if left untreated.ModerateThe problem or diagnosis prevents normal activity or will seriously damage health if left untreated.SevereAdditional narrative about the problem or diagnosis not captured in other fields.CommentThe date this problem or diagnosis was last updated.Last updatedFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionNarrative description about the course of the problem or diagnosis since onset.Course descriptionThe level of confidence in the identification of the diagnosis.Diagnostic certaintyThe diagnosis has been identified with a low level of certainty.SuspectedThe diagnosis has been identified with a high level of certainty.ProbableThe diagnosis has been confirmed against recognised criteria.ConfirmedData captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.Date/time of onsetfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingfalsefalsetruefalsetrue0openEHR-EHR-COMPOSITION.encounter.v1COVID-19 Pneumonia Diagnosis and Treatment (7th edition)Interaction, contact or care event between a subject of care and healthcare provider(s).Encounter@ internal @Treee.g. Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local context or to align with other reference models/formalisms.Extension
\ No newline at end of file
diff --git a/opts/base_opts/tmp/datos_demograficos.es.v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/datos_demograficos_es_v1.opt
similarity index 100%
rename from opts/base_opts/tmp/datos_demograficos.es.v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/datos_demograficos_es_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/datos_demograficos_es_v2.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/datos_demograficos_es_v2.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/datos_demograficos_es_v2.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/datos_demograficos_es_v2.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/registro_de_monitor_de_signos.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/registro_de_monitor_de_signos.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/registro_de_monitor_de_signos.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/registro_de_monitor_de_signos.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/review.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/review.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/review.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/review.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/screening.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/screening.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/screening.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/screening.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/signos_es_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/signos_es_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/signos_es_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/signos_es_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/simple_encounter_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_encounter_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/simple_encounter_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_encounter_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/simple_encounter_es_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_encounter_es_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/simple_encounter_es_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_encounter_es_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/simple_lab_order_en.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_lab_order_en.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/simple_lab_order_en.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_lab_order_en.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_lab_order_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_lab_order_en_v1.opt
new file mode 100644
index 000000000..223648c62
--- /dev/null
+++ b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_lab_order_en_v1.opt
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+
+
+ Document sent from one treating healthcare provider or organisation to another, for the purpose of requesting advice, a service or transfer of care.
+ Request for service
+
+
+ @ internal @
+ Tree
+
+
+ For example: Local hospital departmental information or additional metadata to align with FHIR or CIMI equivalents.
+ Additional information required to capture local context or to align with other reference models/formalisms.
+ Extension
+
+
+
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/simple_vaccination_record_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_vaccination_record_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/simple_vaccination_record_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/simple_vaccination_record_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/sinais_vitais_fhvc_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/sinais_vitais_fhvc_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/sinais_vitais_fhvc_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/sinais_vitais_fhvc_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/sinais_vitais_wout_proportion_fhvc_en_v4.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/sinais_vitais_wout_proportion_fhvc_en_v4.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/sinais_vitais_wout_proportion_fhvc_en_v4.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/sinais_vitais_wout_proportion_fhvc_en_v4.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_all_datatypes_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_all_datatypes_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_all_datatypes_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_all_datatypes_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_all_datatypes_es_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_all_datatypes_es_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_all_datatypes_es_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_all_datatypes_es_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_index_admin_entry_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_index_admin_entry_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_index_admin_entry_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_index_admin_entry_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_index_interval_event_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_index_interval_event_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_index_interval_event_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_index_interval_event_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_index_references_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_index_references_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_index_references_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_index_references_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_index_references_es_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_index_references_es_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_index_references_es_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_index_references_es_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_indexing_evaluation_es_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_indexing_evaluation_es_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_indexing_evaluation_es_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_indexing_evaluation_es_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_indexing_section_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_indexing_section_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_indexing_section_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_indexing_section_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_ism_paths_es_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_ism_paths_es_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/test_ism_paths_es_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/test_ism_paths_es_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/teste_fh_1_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/teste_fh_1_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/teste_fh_1_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/teste_fh_1_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/vital_signs_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/vital_signs_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/vital_signs_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/vital_signs_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/vital_signs_summary_en_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/vital_signs_summary_en_v1.opt
similarity index 100%
rename from opts/e9d13294-bce7-44e7-9635-8e906da0c914/vital_signs_summary_en_v1.opt
rename to opts/e9d13294-bce7-44e7-9635-8e906da0c914/bkp_for_testing/vital_signs_summary_en_v1.opt
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/control_del_peso_es_v1.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/control_del_peso_es_v1.opt
new file mode 100644
index 000000000..ea5d7fdd2
--- /dev/null
+++ b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/control_del_peso_es_v1.opt
@@ -0,0 +1,1806 @@
+
+
+
+
+
+ ISO_639-1
+
+ es
+
+
+ Not Specified
+ Initial
+ Template metadata sample set
+
+
+
+
+
+
+
+
+
+
+
+
+
+
+ ISO_639-1
+
+ es
+
+ Not Specified
+
+
+
+ 96a39a92-ca61-4b24-8928-d595dbe39639
+
+
+ control_del_peso.es.v1
+
+ Control del peso
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+
+ Boolean
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+ String
+ archetype_id/value
+ attribute
+
+
+ C_STRING
+
+ openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
+
+ constraint
+
+
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+
+
+ true
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+
+ true
+ false
+ true
+ 0
+
+
+
+
+
+
+ openEHR-EHR-OBSERVATION.body_weight.v1
+
+
+ Medición del peso corporal de un individuo.
+ Peso corporal
+
+
+ *@ internal @(en)
+ *Simple(en)
+
+
+ *@ internal @(en)
+ *history(en)
+
+
+ Cualquier evento.
+ Cualquier evento.
+
+
+ Peso del individuo.
+ Peso
+
+
+ *@ internal @(en)
+ *state structure(en)
+
+
+ Descripción de la indumentaria del sujeto en el momento de la medición.
+ Indumentaria
+
+
+ La indumentaria, incluyendo calzado, puede incrementar el peso de forma significativa.
+ Totalmente vestido incluyendo calzado
+
+
+ La indumentaria no genera un incremento significativo del peso.
+ Indumentaria ligera/Ropa interior
+
+
+ Sin ropa.
+ Desnudo
+
+
+ *@ internal @(en)
+ *protocol structure(en)
+
+
+ Únicamente con un pañal. Puede incrementar el peso de forma significativa.
+ Pañales
+
+
+ Detalles acerca del dispositivo de pesada.
+ Dispositivo
+
+
+ Observaciones acerca de la medición del peso.
+ Observaciones
+
+
+ Registrar cualquier consideración que pueda influir en la medida del peso ej: amputaciones, momento del ciclo menstrual, etc. (en)
+ Factores de alteración
+
+
+
+ OBSERVATION
+
+ true
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+
+
+
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+
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+
+
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+
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+
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+
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+
+ CLUSTER
+
+ true
+ true
+ false
+ false
+ 0
+ 1
+
+ at0011
+
+
+ Boolean
+ 2007
+ false
+
+ String
+ archetype_id/value
+ attribute
+
+
+ C_STRING
+
+ openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
+
+ constraint
+
+
+
+
+
+ true
+ false
+
+ true
+ false
+ true
+ 0
+
+
+
+
+
+
+ openEHR-EHR-OBSERVATION.height.v1
+
+
+ La altura o longitud corporal es medida desde la coronilla de la cabeza hasta la planta de los pies. La altura es medida con el individuo en posición erguida y la longitud corporal, en posición recostada.
+ Altura/Longitud corporal
+
+
+ *@ internal @(en)
+ *history(en)
+
+
+ Cualquier registro de altura o longitud corporal en un momento determinado.
+ Cualquier evento
+
+
+ *@ internal @(en)
+ *Simple(en)
+
+
+ La longitud corporal desde la coronilla de la cabeza hasta la planta de los pies.
+ Altura/Longitud corporal
+
+
+ *@ internal @(en)
+ *List(en)
+
+
+ Descripción del dispositivo usado para medir la altura o la longitud corporal.
+ Instrumento
+
+
+ *@ internal @(en)
+ *Tree(en)
+
+
+ Posición del individuo durante la medición de estatura.
+ Posición
+
+
+ La altura se mide de pie, sobre ambos pies con el peso distribuido en forma homogénea, con los talones juntos y ambos glúteos y talones en contacto con una placa posterior vertical o pared.
+ De pie
+
+
+ Comentario acerca de la medición de la altura/longitud corporal.
+ Comentario
+
+
+ Registro de todos las aspectos, condiciones o factores que pueden afectar la medición de la altura/longitud corporal, por ejemplo la amputación de miembros inferiores.
+ Factores de confusión
+
+
+ La longitud corporal es medida en una posición recostada y completamente extendida, con la pelvis plana, las piernas extendidas y los pies flexionados.
+ Acostado
+
+
+
+ OBSERVATION
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+ at0015
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+
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+
+
+
+
+ true
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+ true
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+ 0
+
+
+
+
+
+
+ openEHR-EHR-OBSERVATION.body_mass_index.v2
+
+
+ Medición calculada que compara el peso y altura de un individuo
+ Índice de masa corporal
+
+
+ *@ internal @(en)
+ *history(en)
+
+
+ Cualquier registro en el tiempo del Índice de Masa Corporal
+ Cualquier evento
+
+
+ *@ internal @(en)
+ *Single(en)
+
+
+ Índice que describe el cociente entre peso y altura.
+ Índice de Masa Corporal
+
+
+ *@ internal @(en)
+ *List(en)
+
+
+ El método de registro del Índice de Masa Corporal.
+ Método
+
+
+ Índice de Masa Corporal calculado e ingresado automáticamente sin intervención del usuario.
+ Registro automático
+
+
+ Índice de Masa Corporal calculado e ingresado directamente por el usuario.
+ Entrada directa
+
+
+ Fórmula usada para calcular el Índice de Masa Corporal.
+ Fórmula
+
+
+ *For example: the calculation was made using adjusted weight or height.(en)
+ *Narrative description of any issues or factors that may impact on the calculation.(en)
+ *Confounding factors(en)
+
+
+ **(en)
+ *New element(en)
+
+
+ **(en)
+ *New element(en)
+
+
+ *@ internal @(en)
+ *Tree(en)
+
+
+ **(en)
+ *Cluster(en)
+
+
+
+
+
+ SNOMED-CT
+
+ 60621009
+
+
+
+
+
+
+
+ LOINC
+
+ 39156-5
+
+
+
+
+
+ false
+ false
+
+ true
+ false
+ true
+ 0
+
+
+
+
+ openEHR-EHR-COMPOSITION.encounter.v1
+
+
+ control_del_peso.es.v1
+
+
+ Interacción, contacto o evento de cuidado entre un paciente y un proveedor de salud.
+ Encuentro
+
+
+ @ internal @
+ Tree
+
+
+ Información adicional requerida para capturar el contexto local o alinear con otros modelos de referencia o formalismos.
+ Extensión
+
+
+
diff --git a/opts/e9d13294-bce7-44e7-9635-8e906da0c914/covid_19_pneumonia_diagnosis_and_treatment_7th_edition.opt b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/covid_19_pneumonia_diagnosis_and_treatment_7th_edition.opt
new file mode 100644
index 000000000..76e3e4c42
--- /dev/null
+++ b/opts/e9d13294-bce7-44e7-9635-8e906da0c914/covid_19_pneumonia_diagnosis_and_treatment_7th_edition.opt
@@ -0,0 +1,239 @@
+ISO_639-1enXudong LuZhejiang Universitylvxd@zju.edu.cn2020-04-07Heather Leslie<heather.leslie@atomicainformatics.com>Shan Nan<nanshan@zju.edu.cn>Mengyang Li<lmy_86263@zju.edu.cn>Hailing Cai<chl@vico-lab.com>Bin Qi<Qi.Bin@vico-lab.com>Tianhua Tang<11915018@zju.edu.cn>Hongshuo Feng<21915015@zju.edu.cn>InitialTemplate metadata sample set1a36be5935c97561ec3b9a57fb7289d5706E6DA39FA082EE75E0F0D4E4A87F25ISO_639-1enThe template is developed to promote interoperability among systems for the diagnosis and treatment of COVID-19. The data points included in the template were abstracted from the 7th version of Diagnosis and Treatment Guideline of COVID-19 released by the National Health Commission of the People's Republic of China (Printed and distributed on March 3, 2020), the translated English version can be found in https://www.chinalawtranslate.com/en/coronavirus-treatment-plan-7/.openEHRCOVID-19DiagnosisTreatmentCDSThere may be some differences in the guidelines issued by authorities from other countries. Therefore, the specific requirements and clinical environment of the country or region should be examined.abfc7f16-ad25-433c-b90a-eb15d89e60a8COVID-19 Pneumonia Diagnosis and Treatment (7th edition)COVID-19 Pneumonia Diagnosis and Treatment (7th edition)COMPOSITIONtruetruefalsefalse11at0000categorytruetruefalsefalse11DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11openehr433contexttruetruefalsefalse01EVENT_CONTEXTtruetruefalsefalse11other_contexttruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0002Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11COVID-19 Pneumonia Diagnosis and Treatment (7th edition)contenttruetruefalsefalse01SECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Clinical backgrounditemstruetruefalsefalse01OBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0004valuetruetruefalsefalse01DV_DURATIONtruetruefalsefalse11ELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_DURATIONtruetruefalsefalse11falsefalsetruefalsetrue0falsefalsetruefalsetrue1openEHR-EHR-OBSERVATION.age.v0Details about the age of an individual.Age@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeAge based on actual date of birth.Chronological ageAge based on due date.Adjusted ageFor example: pre-term deliveryAdditional narrative about the age of an individual, not captured in other fields.CommentOBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0034valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11S840544004ELEMENTtruetruefalsefalse01at0028valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0031at0032at0033nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Symptomatic/Asymptomatic?CLUSTERtruetruefalsefalse01at0022itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT386661006842290011183300568235000645310031623970036896200126703600762315008ELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0023at0024at0027CLUSTERtruefalsetrue0at0026Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Typical symptom/signCLUSTERtruetruefalsefalse01at0022itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT4224000082717820012142640039117500016183800234095006271825005304534000ELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0023at0024at0027CLUSTERtruefalsetrue0at0026Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.symptom_sign(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Child specific symptom/signfalsefalsetruefalsetrue0falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0007itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0021Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-OBSERVATION.symptom_sign_screening.v0An individual- or self-reported questionnaire screening for symptoms and signs.Symptom/sign screening questionnaire@ internal @HistoryDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeName of the symptom or sign being screened.Symptom or sign namePresence of the symptom or sign.Presence?@ internal @Item treeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionGrouping of data elements related to screening for a single symptom or sign.Specific symptom/signThe specific symptom or sign is present.PresentThe specific symptom or sign is not present.AbsentAdditional narrative about the symptoms and signs, not captured in other fields.Overall commentAdditional structured details related to a specific symptom or sign.Symptom/sign detailsIt is not known whether the symptom or sign is present or absent.UnknownPresence of any relevant symptoms or signs.Presence of any symptoms or signs?Partial dates are allowed.The date/time when any symptoms or signs were first noticed.Onset of any symptoms or signsSymptoms or signs are present.PresentSymptoms or signs are not present.AbsentIt is not known whether any symptoms or signs are present or absent.UnknownFor example: screening for an infectious disease, such as SARS-COV-2.The reason for overall screening.Screening purposeAdditional narrative about the specific symptom or sign, not captured in other fields.CommentNarrative description about all symptoms or signs.DescriptionSuspected disease caused by SARS-CoV-2FeverFatigueDry coughNasal congestionNasal dischargeSore throatMuscle painShortness of breathDiarrheaVomitingDrowsinessLethargyConvulsionInfant feeding problemDehydrationDistressed breathingCryingSNOMED-CT410515003SNOMED-CT410516002SNOMED-CT261665006SNOMED-CT410515003SNOMED-CT410516002SNOMED-CT261665006OBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0022itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT38908700634150046778200576571007594550096477900827942005576530007738600639819200323453200165710008ELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0023at0024at0027CLUSTERtruefalsetrue0at0039Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.clinical_evidence\.v1constraintfalsefalsetruefalsetrue1ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_DURATIONtruetruefalsefalse11DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0036at0037at0038falsefalsetruefalsetrue0falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0007itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0021Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Condition/finding screening questionnaireopenEHR-EHR-OBSERVATION.condition_screening.v0An individual- or self-reported questionnaire screening for conditions, including problems, diagnoses and pregnancy.Condition screening questionnaire@ internal @HistoryDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeName of the condition being screened.Condition namePresence of the condition.Presence?Partial dates are allowed.The date/time when the condition was first noticed by the individual or diagnosed by a clinician.Onset@ internal @Item treeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionGrouping of data elements related to screening for a single condition.Specific conditionThe specific condition is present.PresentThe specific condition is not present.AbsentAdditional narrative about the conditions, not captured in other fields.Overall commentIt is not known whether the condition is present or absent.UnknownPresence of any relevant conditions.Presence of any conditions?Partial dates are allowed.The date/time when any conditions were first noticed.Pregnancy gestationConditions are present.PresentConditions are not present.AbsentIt is not known whether any conditions are present or absent.UnknownFor example: pre-operative screening.The reason for overall screening.Screening purposeAdditional narrative about the specific condition, not captured in other fields.CommentBetween first day of last period and the end of week 12.First trimesterBetween week 13 and week 28.Second trimesterAfter week 28.Third trimesterFor example: Clinical evidence or a disease specific grading scale.Additional details about the specific condition.Condition detailsHypoxemiaCyanosisAcute respiratory distress syndromeSeptic shockMetabolic acidosisBlood coagulation disorderShockMultiple organ failurePregnantComorbid conditionsImmunodeficiencyAcute respiratory failureSNOMED-CT410515003SNOMED-CT410516002SNOMED-CT261665006SNOMED-CT410515003SNOMED-CT410516002SNOMED-CT261665006OBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0022itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT40617009305351004ELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0023at0024at0027nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Carried out?CLUSTERtruefalsetrue0at0036Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.inspired_oxygen\.v1constraintfalsefalsetruefalsetrue1falsefalsetruefalsetrue0falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0007itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0021Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-OBSERVATION.management_screening.v0An individual- or self-reported questionnaire screening for management or treatment carried out.Management/treatment screening questionnaire@ internal @HistoryDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeName of the management or treatment activity being screened.Activity nameDid the management or treatment activity take place?Actioned?Partial dates are allowed.The date/time when the management or treatment activity was carried out.Date actioned@ internal @Item treeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionGrouping of data elements related to screening for a single management or treatment activity.Specific management/treatment activityThe specific management activity was carried out.ActionedThe specific management activity was not carried out.Not actionedAdditional narrative about all management and treatment activities, not captured in other fields.Overall commentIt is not known whether the management activity was carried out.UnknownFor example: screening for an infectious disease, such as SARS-COV-2.The reason for overall screening.Screening purposeAdditional narrative about the specific management or treatment activity, not captured in other fields.CommentFor example: Details about oxygen therapy.Additional details about the specific activity.Activity detailsMechanical ventilationAdmission to intensive care unitSNOMED-CT385652002SNOMED-CT385660001SNOMED-CT261665006SECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Vital signsitemstruetruefalsefalse01OBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0002eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0003datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11falsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0029itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0056Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.environmental_conditions\.v1|openEHR-EHR-CLUSTER\.environmental_conditions\.v0constraintCLUSTERtruetruefalsefalse01at0057Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.level_of_exertion\.v1|openEHR-EHR-CLUSTER\.level_of_exertion\.v0constrainttruefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Any point in time eventfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0020itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0064Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative\.v1constraintCLUSTERtruetruefalsefalse01at0059Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device\.v1constraintCLUSTERtruefalsetrue0at0062truefalsetruefalsetrue0openEHR-EHR-OBSERVATION.body_temperature.v2A measurement of the body temperature, which is a surrogate for the core body temperature of the individual.Body temperature@ internal @Tree@ internal @HistoryDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any eventThe measured temperature.Temperature@ internal @ProtocolSimple description about the site of measurement.Location of measurementTemperature is measured within the mouth.MouthTemperature is measured from within the external auditory canal.Ear canalTemperature is measured from the skin of the axilla with the arm positioned down by the side.AxillaTemperature measured within the rectum.RectumTemperature is measured within the nasopharynx.NasopharynxTemperature is measured in the urinary bladder.Urinary bladderTemperature is measured within the vascular system.IntravascularState information about the patient.StateThe degree of exposure of the individual at the time of measurement.Body exposureNo clothing, bedding or covering.NakedThe person is covered by a lesser amount of clothing or bedding than deemed appropriate for the environmental circumstances.Reduced clothing/beddingThe person is covered by an amount of clothing or bedding deemed appropriate for the environmental circumstances.Appropriate clothing/beddingThe person is covered by an increased amount of clothing or bedding than deemed appropriate for the environmental circumstances.Increased clothing/beddingNarrative description of the conditions applied to the subject that might influence their measured body temperature.Description of thermal stressTemperature is measured from exposed skin.SkinTemperature is measured within the vagina.VaginaTemperatue is measured within the oesophagus.OesophagusTemperature is measured in the inguinal skin crease between the leg and abdominal wall.Inguinal skin creaseDetails about the environmental conditions at the time of temperature measurement.Environmental conditionsDetails about the exertion of the person at the time of temperature measurement.ExertionDetails about the device used to measure body temperature.DeviceTemperature is measured at the temple, over the superficial temporal artery.TempleTemperature is measured on the forehead.ForeheadFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.ExtensionAdditional comment about the body temperature measurement not captured in other fields.CommentStructured details about the location of measurement.Structured measurement locationThe first day of menstruation is considered to be Day 1 of each menstrual cycle.Current day of the menstrual cycle.Day of menstrual cycleAdditional issues or factors that may impact on the measurement of body temperature, not captured in other fields.Confounding factorsLNC2058310-5SNOMED-CT386725007OBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0004valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11falsefalsetruefalsetrue0statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0022itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0055Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruetruefalsefalse01at0037Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Any point in time eventfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0057itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0058Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-OBSERVATION.respiration.v2The characteristics of spontaneous breathing by an individual.Respiration@ internal @historyDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @ListThe frequency of spontaneous breathing.RateThe regularity of spontaneous breathing.RegularityThe breathing pattern is regular.RegularThe breathing pattern is not regular.IrregularCoding with a terminology is preferred, where possible. For example: Normal breathing; Evidence of respiratory distress; Kussmaul's respiration; Cheyne-Stokes respiration; or Apnoeic episodes. Multiple statements are allowed.Single word, phrase or brief description which represents the clinical meaning and significance of the respiration findings.Clinical interpretationThe depth of spontaneous breathing.DepthNormal depth of breathing.NormalShallow depth of breathing.ShallowDeep breathing.Deep@ internal @ListFor example: noting respiratory distress, use of accessory muscles or intermittent apnoea; noting characteristics such as stridor, sighing, grunting, groaning, gasping.
+Conducting a full respiratory examination, then some of these findings might be more appropriately recorded as part of examination findings.A narrative description about the spontaneous breathing of the individual.Clinical descriptionVariable depth of breathing.VariableThe individual's level of exertion during, or just prior to, the observation.Details about physical exertion being undertaken during the examination.ExertionAssumed values of 21% oxygen concentration, Fi02 of 0.21 and oxygen flow rate of 0 l/min or 0 ml/min.Details of the amount of oxygen being delivered to the individual at the time of observation.Inspired oxygenFor example: level of anxiety, pain, feeding in infants, tracheostomy.Identification of any issues or incidental factors that may impact on interpretation of the observation.Confounding factors@ internal @TreeFor example: local information requirements or additional metadata to align with FHIR.Additional information required to capture local context or to align with other reference models/formalisms.ExtensionThis data element may be useful in extreme situations where a formal measurement of respiration rate is not possible. For example: a subject is unconscious and distant to the observer, such as trapped in a car or has fallen down a cliff. Presence of respiration can be implied if the 'Rate' >0 breaths/min.Observation of spontaneous respiration.PresenceRespiratory movements are observed.PresentRespiratory movements are not detected on observation.Not detectedThe body position of the individual during the observation.Body positionThe individual was standing, walking or running.Standing/uprightThe individual was sitting (for example, on a bed or chair).SittingThe individual was reclining at an approximate angle of 45 degrees, with the legs elevated to the level of the pelvis.RecliningThe individual was lying on their back.LyingAdditional narrative about the respirations, not captured in other fields.CommentThe individual was lying on their front.ProneOBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0006valuetruetruefalsefalse01DV_PROPORTIONtruetruefalsefalse11numeratortruetruefalsefalse11REALtruetruefalsefalse11truetruefalsefalse0100typetruetruefalsefalse11INTEGERtruetruefalsefalse112CLUSTERtruefalsetrue0at0054Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.waveform(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0060Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue0statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0014itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0034Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.level_of_exertion(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruetruefalsefalse01at0015Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.inspired_oxygen(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0007itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0018Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0059Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-OBSERVATION.pulse_oximetry.v1Blood oxygen and related measurements, measured by pulse oximetry or pulse CO-oximetry.Pulse oximetry@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeSpO₂ is defined as the percentage of oxyhaemoglobin (HbO₂) to the total concentration of haemoglobin (HbO₂ + deoxyhaemoglobin) in peripheral blood.The saturation of oxygen in the peripheral blood, measured via pulse oximetry.SpO₂@ internal @ListFor example: Right index finger, left earlobe. Coding with a terminology is preferred, if possible.The site of the measurement sensor.Sensor site@ internal @TreeAssumed values of 21% oxygen concentration, Fi0₂ of 0.21 and oxygen flow rate of 0 l/min or 0 ml/min.Details of the amount of oxygen available to the subject at the time of observation.Inspired oxygenFor example, motion, pain, poor perfusion, infant feeding, peripheral hypothermia, sedation.Comment on and record other incidental factors that may be affect interpretation of the observation.Confounding factorsDetails of the non-invasive oximetry device used.Oximetry deviceDetails about physical activity undertaken at the time of measurement.ExertionA text comment about the pulse oximetry result.CommentThe oxygen content of the peripheral blood, calculated based on pulse oximetry and pulse CO-oximetry.SpOCThe saturation of carboxyhaemoglobin in the peripheral blood, measured via pulse CO-oximetry.SpCOThe saturation of methaemoglobin in the peripheral blood, measured via pulse CO-oximetry.SpMetA waveform reading associated with the oximetry measurement.WaveformCoding with a terminology is preferred, if possible. For example, normal oxygen saturation or hypoxaemia.Single word, phrase or brief description which represents the clinical meaning and significance of the measurements.Interpretatione.g. Local hospital departmental infomation or additional metadata to align with HL7 or CDISC equivalents.Additional information required to capture local context or to align with other reference models/formalisms.ExtensionDetails of a series of oximetry readings, other than waveforms, expressed as a multimedia image or series of images. Waveforms should be recorded using the Waveform slot and associated cluster archetype.Multimedia imageSensor site relative to the ductus arteriosus in neonates, to determine whether the blood supply to limb of the sensor site is pre- or post-ductal in cases of patent ductus arteriosus.Pre/post-ductalThe sensor site is pre-ductal.Pre-ductalThe sensor site is post-ductal.Post-ductalUnable to assess whether the sensor site is pre- or post-ductal.IndeterminateSNOMED-CT431314004SNOMED-CT16206004SNOMED-CT448703006SNOMED-CT277923006LOINC59408-5LOINC20081-6LOINC57800-5LOINC86904-0LOINC2614-6falsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Laboratory testsitemstruetruefalsefalse01OBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC94500-6CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Nasopharyngeal secretionsSputumLower respiratory tract secretionsCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC94500-6ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT10828004720735008260385009CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceSARS coronavirus 2 RNAPositivePresumptive positiveNegativeCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintELEMENTtruetruefalsefalse01at0121valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11RT-PCRNext Generation SequencingCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11SARS coronavirus 2 RNAopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisSARS coronavirus 2 RNAOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC94503-0CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum or plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC94505-594506-3ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11mg/dlg/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceSARS coronavirus 2 Ab.IgGSARS coronavirus 2 Ab.IgMCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11SerologyopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisSARS coronavirus 2 Ab.IgG & IgM panelOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC57021-8CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11BloodCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT6690-2789-8718-74544-3787-2785-6786-4777-3731-0751-8742-7711-2704-7ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceLeukocytesErythrocytesHemoglobinHematocritErythrocyte mean corpuscular volumeErythrocyte mean corpuscular hemoglobinErythrocyte mean corpuscular hemoglobin concentrationPlateletsLymphocytesNeutrophilsMonocytesEosinophilsBasophilsCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Complete blood count & differentialopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisCBC W Auto Differential panelOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC24336-0CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11CLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2744-12019-82703-71960-41925-7ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequencepHpCO2pO2HCO3Base excessCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0052valuetruetruefalsefalse01DV_PROPORTIONtruetruefalsefalse11numeratortruetruefalsefalse11REALtruetruefalsefalse11truetruefalsefalse01typetruetruefalsefalse11INTEGERtruetruefalsefalse111CLUSTERtruefalsetrue0at0058Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.inspired_oxygen.v1The amount of oxygen being delivered, or to be delivered, to the patient given as a fraction, percentage or indirectly as a flow rate.Inspired oxygenFor example '5 l/min'.Oxygen flow rate given to an individual.Flow rateFor example: '0.28'.Fraction of oxygen in inspired air.FiO₂For example: '24 %'Percentage of oxygen in inspired air.Percent O₂Intended to capture only simple description / terms, for example: 'nasal prongs'. The 'Oxygen delivery detail' slot may be used for more detailed or complex recording.The method used to deliver the oxygen.Method of oxygen deliveryWhere 'On air' is set to true, Flow rate, FiO₂ and Percent O₂ should not be recorded. Conversely 'On air' should be omitted if Flow rate, FiO₂ or Percent O₂ are recorded.The patient is receiving air, equivalent to 21% O₂ or 0.21 FiO₂ and an oxygen flow rate of 0 litres per minute.On airFor example details of humidification or assisted ventilation.Further details of the method of oxygen delivery.Oxygen delivery detailfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Arterial blood gasesopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
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+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisGas panel - Arterial bloodOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC1988-5CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC1988-5ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11mg/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceC reactive proteinCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11C reactive proteinopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisC reactive proteinOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC26881-3CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC26881-3ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceInterleukin 6CLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Interleukin 6openEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisInterleukin 6OBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC24325-3CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2885-21751-71975-21968-76768-61920-81742-6ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceProtein [Mass/volume] in Serum or PlasmaAlbumin [Mass/volume] in Serum or PlasmaBilirubin.total [Mass/volume] in Serum or PlasmaBilirubin.direct [Mass/volume] in Serum or PlasmaAlkaline phosphatase [Enzymatic activity/volume] in Serum or PlasmaAspartate aminotransferase [Enzymatic activity/volume] in Serum or PlasmaAlanine aminotransferase [Enzymatic activity/volume] in Serum or PlasmaCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Liver function panelopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisLiver function panelOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2157-6CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2157-6ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11[iU]/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceCreatine kinaseCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Creatine kinaseopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisCreatine kinaseOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC6598-7CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC6598-7ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceTroponin T.cardiac [Mass/volume] in Serum or PlasmaCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11TroponinsopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisTroponin T.cardiac [Mass/volume] in Serum or PlasmaOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2639-3CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2639-3ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceMyoglobin [Mass/volume] in Serum or PlasmaCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11MyoglobinopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisMyoglobin [Mass/volume] in Serum or PlasmaOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC30341-2CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC30341-2ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceErythrocyte sedemination rateCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11ESRopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisErythrocyte sedemination rateOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC48067-3CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC48067-3ELEMENTtruefalsetrue0at0001CLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceFibrin D-dimerCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Fibrin D-dimeropenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisFibrin D-dimerOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2524-7CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2524-7ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11[iU]/Lmmol/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceLactate [Moles/volume] in Serum or PlasmaCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruefalsetrue0at0101valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11falsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11LactateopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisLactate [Moles/volume] in Serum or PlasmaOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2532-0CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC2532-0ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11[iU]/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceLactate dehydrogenase [Enzymatic activity/volume] in Serum or PlasmaCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Lactate dehydrogenaseopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisLactate dehydrogenase [Enzymatic activity/volume] in Serum or PlasmaOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC31682-5CLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Serum/plasmaCLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.physical_properties(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.body_fluid(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0013Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_circle(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0015valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11DV_INTERVAL<DV_DATE_TIME>truetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0083Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0085Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0068Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0096Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.specimen.v1For example: Tissue or body fluid.A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.SpecimenSometimes called the Accession Identifier. Specimen containers, for example vacuum vials or tissue cassettes, have their own identitiers which may be recorded in the 'Container identifier' element in the 'Specimen container' archetype.A unique identifier of the specimen, normally assigned by the laboratory.Specimen.accessionIdentifierLaboratory specimen identifierFor example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.Unique identifier of the parent specimen, where the specimen is split into sub-samples.Parent specimen identifierFor example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.Hazard warningFor example: venepuncture, biopsy, resection. Coding of the collection method with a terminology is preferred, where possible. If the collection method is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.The method of collection used.Specimen.collection.methodCollection methodFor example: 'fasting'; 'full bladder'; 'sterile field'; or special instructions on the handling or immediate processing of the sample, such as 'centrifuge on receipt'. This data element also be used to document any known deviations from collection or handling instructions, for example that the patient had not fasted, even when this had been originally requested. Coding of the 'Sampling context' with a terminology is preferred, where possible.
+
+If this archetype is used within an INSTRUCTION archetype, the context will reflect the intended or desired conditions at sample collection. If this archetype is used for representing an ACTION archetype pathway step which correlates with the collection being performed or completed, the context will be reflecting the conditions that existed at sample collection and this may also be copied to the 'Confounding factors' element of the OBSERVATION.laboratory_test_result archetype.The context in which the specimen is collected.Sampling contextUtilise the more detailed archetypes to describe structured or more complex anatomical sites, or to support recording the source site at run-time by the application. If the body site has been fully identified in the 'Source site' data element, this SLOT becomes redundant.A structured description of the area of the body from where the specimen is collected.Specimen.collection.sourceSiteStructured source siteThis datetime will be captured primarily in the INSTRUCTION timing, ACTION time or OBSERVATION times. However, as this is a critical piece of information, it can be useful to also associate it directly with the specimen itself.The date and time that collection has been ordered to take place or has taken place.Collection date/timeFor example: Volume, mass, circumference, colour, smell, turbidity. This element can be used to specify the properties of the specimen to be collected, in the context of an INSTRUCTION archetype, or the properties of the specimen which was collected, in the context of an ACTION or OBSERVATION archetype. For example, an INSTRUCTION may request the collection of 20 ml of blood, while the corresponding ACTION records that only 15 ml was collected.Physical dimensions, mass or non-measurable properties of the specimen.Specimen.collection.quantityPhysical propertiesFor example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.The type of specimen.Specimen.typeSpecimen typeThe date and time that the sample was received at the laboratory.Specimen.receivedTimeDate/time receivedThis element is intended to be used to record a judgement about whether or not the specimen quality was good enough for testing, and whether or not testing has been carried out. Coding of the specimen quality issues with a terminology is preferred, where possible.Information about whether the specimen was adequate for testing.Adequacy for testingCoding of the specimen quality issues with a terminology is preferred, where possible.A specific quality issue with a specimen.Specimen quality issueAdditional narrative about the specimen not captured in other fields.Specimen.noteCommentThe specimen was haemolysed.HaemolysedThe specimen was lipaemic.LipaemicAn incorrect additive such as a transport medium or preservative was added to the specimen.Incorrect additiveThe available amount of specimen was insufficient to undertake the examination.Insufficient amountThe specimen is of sufficient quality to allow reporting.SatisfactoryThe specimen is unsatisfactory but has been analysed.Unsatisfactory - analysedThe specimen is unsatisfactory and has not been analysed.Unsatisfactory - not analysedFor example: laboratory outpatient clinic, at home, or hospital ward. This specifies the type of specimen collection location within the healthcare environment. The specimen collection setting may provide additional information relevant to the analysis of the result.Identification of the physical setting in which the specimen is collected.Collection settingFor example: Staining or fixation.Structured details about preparation or processing of the specimen.Processing detailsThis element is intended to be used where the specimen has already been collected and the actual collector is known.Identifier of the person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector identifierThe person or organisation responsible for collecting the specimen.Specimen.collection.collectorSpecimen collector detailsNarrative description about the collection of the specimen.Collection descriptionFor example: Number of buckets, jars, vials, tubes, blocks, slides or grids.The total number of physical units holding this specimen.Number of containersFor example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.Addtional details related to specific collection methods.Additional collection detailsDetails about containers used.Container detailsFor example: 'wound on left calf', 'IV cannula right arm', 'right kidney'.
+Coding of the name of the source site with a terminology is preferred, where possible. Use this data element to record precoordinated source sites. If the requirements for recording the source site are determined at run-time by the application or require more complex modelling such as relative locations then use the 'Structured source site' SLOT in this archetype. If the source site is included in the 'Specimen type' via precoordinated codes, this data element becomes redundant.Identification of the body site or other location from where the specimen is collected.Source siteFor example: 'Requester ID', 'Archive ID, 'Biobank ID'.A unique identifier of the specimen, assigned by a party external to the laboratory.Specimen.identifierExternal identifierThe specimen was icteric.IctericAn error arose when handling the specimen. For example: Incorrect storage, broken container.Handling errorThe specimen was too old to analyse or to analyse accurately.AgeThe specimen could not be analysed for technical reasons.Technical failureStructured details about transport of the specimen.Transport detailsThe specimen was clotted.ClottedThe specimen was labelled incorrectly.Incorrectly labelledFor example the scanned image of a histopathology slide.Structured details about a digital representation of the specimen.Digital representationCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11LOINC31682-5ELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_QUANTITYtruetruefalsefalse11[iU]/LCLUSTERtruefalsetrue0at0014Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.laboratory_test_analyte.v1The result of a laboratory test for a single analyte value.Laboratory analyte resultFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The value of the analyte result.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Analyte resultAdditional narrative about the analyte result, not captured in other fields.Observation.noteNTE.3CommentFor example, 'within normal limits for age and sex'.Additional advice on the applicability of the reference range to this result or may carry text or coded textual guidance as to whether the result is within the normal range.Reference range guidanceThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.The status of the analyte result value.Observation.statusOBX.11Result statusThe date and time that the analyte result was issued for the recorded ‘Result status’.Observation.issuedOBX.19Result status timeFurther detail regarding an individual result.Analyte result detailThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedThe Test Result has been withdrawn following previous Final release.Entered in errorThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe value for this element is normally supplied in a specialisation, in a template or at run-time to reflect the actual analyte. For example: 'Serum sodium', 'Haemoglobin'. Coding with an external terminology is strongly recommended, such as LOINC, NPU, SNOMED CT, or local lab terminologies.The name of the analyte result.Observation.codeOBX.3Analyte nameIn many jurisdictions the 'Result status' is assumed to include medical validation i.e. a 'final' result will be assumed to be medically validated, but in others this will be recorded and reported separately using this data element.The date and time that the analyte result was validated in the laboratory by a healthcare practitioner.Validation timeIn some situations, a single Laboratory test result archetype will contain multiple Specimen archetypes and multiple Analyte result archetypes. In these situations, this 'Specimen' data element is needed to be able to connect the results with the correct specimens.Identification of the specimen used for the analyte result.SpecimenFor example: ''1' '2', '3'. Where multiple analyte results are reported, the 'Analyte result sequence' makes the order in which they were reported explicit.The intended position of this analyte result within the overall sequence of analyte results.Analyte result sequenceProcalcitoninCLUSTERtruefalsetrue0at0122Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0118Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0112itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0114Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0falsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0017Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0110Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0117Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11ProcalcitoninopenEHR-EHR-OBSERVATION.laboratory_test_result.v1The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.Laboratory test result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Tree@ internal @TreeA test result may be for a single analyte, or a group of items, including panel tests. It is strongly recommended that 'Test name' be coded with a terminology, for example LOINC or SNOMED CT. For example: 'Glucose', 'Urea and Electrolytes', 'Swab', 'Cortisol (am)', 'Potassium in perspiration' or 'Melanoma histopathology'. The name may sometimes include specimen type and patient state, for example 'Fasting blood glucose' or include other information, as 'Potassium (PNA blood gas)'.Name of the laboratory investigation performed on the specimen(s).Test nameThis slot is intended to carry details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.
+
+The receiving laboratory may either perform the test or refer it to another laboratory. Where a different laboratory is responsible for performing the testing on specific analytes, it would be expected that these details would be carried in the 'Analyte result detail' SLOT within the CLUSTER.laboratory_test_analyte archetype.Details of the laboratory which received the request and has overall responsibility to manage reporting of the test, even if other labs perform specific aspects.Receiving laboratoryThe 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.Details of additional clinicians or organisations who require a copy of the test result.Distribution listThis is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.PartialThe Test result is complete and verified by an authorised person.FinalThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.AmendedFor example: 'Pattern suggests significant renal impairment'. The content of the conclusion will vary, depending on the investigation performed. This conclusion should be aligned with the coded 'Test diagnosis'.Narrative description of the key findings.ConclusionEquivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierAssigning an identifier to a request by the Laboratory lnformation System (LIS) 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.The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).Receiver order identifierIf the specimen type is sufficiently specified with a code in the Test name, then this additional data is not required. Linking results to specific specimens may be recorded using 'Specimen identifier' elements in both the CLUSTER.specimen and the various results CLUSTER archetypes.Details about the physical substance that has been analysed.Specimen detailThis identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.Laboratory internal identifierThe values have been specifically chosen to match those in the HL7 FHIR Diagnostic report, historically derived from HL7v2 practice. Other local codes/terms can be used via the Text 'choice'.
+
+This element is multiple occurrence to cater for the use cases where statuses for different aspects of the result have been split into several elements.The status of the laboratory test result as a whole.Overall test statusThe result is unavailable because the test was not started or not completed (also sometimes called 'aborted').CancelledThe date and/or time that ‘Overall test status’ was issued.Overall test status timestampThis is intended to be a general categorisation and not to capture the organisational name of the laboratory. For example: anatomical pathology, immunology and transfusion medicine, medical microbiology, clinical pharmacology, medical genetics, medical biochemistry. Alternatively more granular sub categories or sub disciplines, such as endocrinology, haematology, and allergology services, may be used. This may assist clinicians in filtering between categories of results. Coding with a terminology is desirable, where possible.The diagnostic service or discipline that is responsible for the laboratory test result.Diagnostic service categoryDetails of the clinician or organisation requesting the laboratory test result.RequesterIn most situations there is one test request and a single corresponding test result, however this repeating cluster allows for the situation where there may be multiple test requests reported using a single test result.
+
+As an example: 'a clinician asks for blood glucose in one request and Urea/electrolytes in a second request, but the lab analyser does both and the lab wishes to report these together'.Details about the test request.Test request detailsThis SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.Results of the test performed on the specimen(s).Test resultFor example: 'Severe hepatic impairment', 'Salmonella contamination'. Coding of the diagnosis with a terminology is strongly recommended, where possible. This diagnosis should be aligned with the narrative in the 'Conclusion'.Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.Test diagnosisThis data element may include a link to the original clinical information provided in the test request.Description of clinical information available at the time of interpretation of results.Clinical information providedAdditional narrative about the test result not captured in other fields.CommentThis data element is to be used when the test requested differs from the test actually performed by the laboratory.Name of the original laboratory test requested.Original test requested nameThe existence of the test is registered in the Laboratory Information System, but there is nothing yet available.RegisteredFor example: 'details of ELISA/nephelometry'.Structured details about the method of analysis, device or interpretation used.Testing detailsTrue if the test was performed directly at Point-of-Care (POCT).This indicates whether the test was performed directly at Point-of-Care (POCT) as opposed to a formal result from a laboratory or other service delivery organisation.Point-of-care test@ internal @Tree'Confounding factors' should be reserved for uncontrolled/unplanned issues of patient state/physiology that might affect interpretation, for example 'recent exercise' or 'recent tobacco smoking'.
+
+Known or required preconditions, such as 'fasting' should be carried in the 'Sampling conditions' element within the CLUSTER.specimen archetype . In some cases preconditions are captured as part of the test name, for example 'Fasting blood glucose'.
+
+Known issues with specimen collection or handling, such as 'prolonged use of tourniquet' or 'sample haemolysed', should be carried in the 'Specimen quality' elements within CLUSTER.specimen archetype.
+
+Coding with a terminology is desirable, where possible.Issues or circumstances that impact on the accurate interpretation of the measurement or test result.Confounding factorsFor example: Last Normal Menstrual Period (LNMP).Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.Structured confounding factorsThe result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.CorrectedThe Test Result has been withdrawn following previous Final release.Entered in errorFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionMultiple formats are allowed but they should represent equivalent clinical content.Digital image, video or diagram representing the test result.Multimedia representationSubsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.AppendedVerified early results are available, but not all results are final. This is a sub-category of 'Partial'.PreliminaryCoding with a terminology is desirable, where possible.Description about the method used to perform the test.Test methodFor example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.A structured or complex diagnosis for the laboratory test.Structured test diagnosisProcalcitoninOBSERVATIONtruefalsetrue0at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01POINT_EVENTtruefalsetrue0at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0004valuetruetruefalsefalse01DV_PROPORTIONtruetruefalsefalse11typetruetruefalsefalse11INTEGERtruetruefalsefalse110falsefalsetruefalsetrue0falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0005itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0006Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-OBSERVATION.pf_ratio.v0Also known as the PF ration, Carrico index or Horowitz quotient.Ratio between the partial pressure of oxygen in blood (PaO2) and the fraction of oxygen in the inhaled air (FiO2).PaO2/FiO2 ratio@ internal @HistoryDefault, unspecified point in time event which may be explicitly defined in a template or at run-time.Any point in time event@ internal @TreeCalculated ration value.PaO2/FiO2 ratio@ internal @Item treeFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.Extensionfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Imaging testsitemstruetruefalsefalse01OBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT399208008CLUSTERtruefalsetrue0at0006Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Pleural effusionConsolidationPatchy shadowsInterstitial changesInfiltrationCLUSTERtruefalsetrue0at0034Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location\.v1constraintELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0035at0036at0037CLUSTERtruefalsetrue0at0014falsefalsetruefalsetrue1openEHR-EHR-CLUSTER.imaging_finding.v0A single finding in an imaging examination.Imaging findingFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The presence or absence of the finding.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Presence?Additional narrative about the finding, not captured in other fields.Observation.noteNTE.3CommentAdditional structured detail about the finding.Structured detailCoding with an external terminology is strongly recommended.The name of the finding.Observation.codeOBX.3Finding nameNarrative description about the observed clinical finding.DescriptionNarrative description about the difference between a previous finding and the finding in this report.Comparison to previousThe finding is improving compared to previous imaging examinations.ImprovingThe finding is unchanged compared to previous imaging examinations.UnchangedThe finding is worsening compared to previous imaging examinations.WorseningSimple description of anatomical location.Anatomical locationStructured details about the location of the finding.Structured anatomical locationThe finding is observed in the image.PresentThe finding is not observed in the image.AbsentIt is not possible to determine if the finding is present or absent.IndeterminateELEMENTtruetruefalsefalse01at0020valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11No obvious signs of pneumoniaPresenting with pneumoniaCLUSTERtruefalsetrue0at0045Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0047itemstruetruefalsefalse01falsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11BaselineEVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT399208008CLUSTERtruefalsetrue0at0006Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Pleural effusionConsolidationPatchy shadowsInterstitial changesInfiltrationCLUSTERtruefalsetrue0at0034Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location\.v1constraintELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0035at0036at0037CLUSTERtruefalsetrue0at0014ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11ImprovingUnchangedWorseningfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.imaging_finding.v0A single finding in an imaging examination.Imaging findingFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The presence or absence of the finding.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Presence?Additional narrative about the finding, not captured in other fields.Observation.noteNTE.3CommentAdditional structured detail about the finding.Structured detailCoding with an external terminology is strongly recommended.The name of the finding.Observation.codeOBX.3Finding nameNarrative description about the observed clinical finding.DescriptionNarrative description about the difference between a previous finding and the finding in this report.Comparison to previousThe finding is improving compared to previous imaging examinations.ImprovingThe finding is unchanged compared to previous imaging examinations.UnchangedThe finding is worsening compared to previous imaging examinations.WorseningSimple description of anatomical location.Anatomical locationStructured details about the location of the finding.Structured anatomical locationThe finding is observed in the image.PresentThe finding is not observed in the image.AbsentIt is not possible to determine if the finding is present or absent.IndeterminateELEMENTtruetruefalsefalse01at0020valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11No obvious signs of pneumoniaPresenting with pneumoniaCLUSTERtruefalsetrue0at0045Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0047itemstruetruefalsefalse01falsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Follow upfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0025itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0041Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0026Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0046Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Chest x-rayopenEHR-EHR-OBSERVATION.imaging_exam_result.v0Record the findings and interpretation of an imaging examination performed.Imaging examination result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeCoding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex.The name of the imaging examination or procedure performed.Test nameAlso known as 'Examination type'. For example: Ultrasound; Computed tomography; or X-ray. Coding with a terminology is desirable, where possible. If the modality is specified by a code in the Examination result name, then this field may be redundant.Type of equipment that originally acquired the image or series of images.ModalityIdentification of the anatomical site related to a specific finding will be recorded within each instance of CLUSTER.imaging_finding.Structured detail about the anatomical site related to the entire result.Structured anatomical siteThe status of the examination result as a whole.Overall result statusNarrative description of the clinical findings.FindingsNo result yet available.RegisteredThis is an initial or interim result: data may be missing or verification not been performed.InterimThe result is complete and verified by the responsible radiologist.FinalThe result has been modified subsequent to being Final, and is complete and verified by the radiologist.AmendedThe result is not available because the examination was not started or completed.Cancelled / AbortedThis may include a link to the clinical information provided in the original examination request. If other sources of clinical information have been used, this should be clearly stated using this data element.Description of clinical information available at the time of interpretation of results.Clinical information providedThis data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result.Single word, phrase or brief description representing the likely condition or diagnosis.Imaging diagnosisAlso referred to as 'Opinion' or 'Impression'.Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate.ConclusionFor example: a note that the film was given to the patient.Additional narrative about the examination not captured in other fields.CommentThe date and/or time that the result was issued for the recorded 'Examination result status'.DateTime result issued@ internal @TreeDemographic details about the receiving imaging service performing the imaging test.Receiving imaging serviceDetails concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype.Examination request detailsThe local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier.Requester order identifierIdentification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed.Examination requested nameDetails about the clinician or organisation requesting the imaging examination.RequesterThe local identifier assigned to the examination order by the order filler, usually by the Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number.Receiver order identifierUnique identifier of this study allocated by the imaging service.DICOM study identifierThe local identifier given to the imaging examination report.Report identifierImages referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images.Image detailsUnique identifier of this image allocated by the imaging service (often the DICOM image instance UID).Image identifierUnique identifier of this series allocated by the imaging service.DICOM series identifierThe name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible.ViewDescription of the subject of care's positon when the image was performed.PositionSpecific date/time the imaging examination was performed.Image DateTimeAn attached or referenced image of a current view.ImageAdditional structured details of technical details and procedure.Structured techniqueStructured details about each imaging finding.Imaging findingsDigital image or video representing the exam result.Image representationFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.Extension@ internal @TreeNarrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result.Confounding factorsFor example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media.Narrative description about the technical details and procedure.TechniqueDetails about the image being reported.Reported imageFor example: narrative description about progression/worsening of a condition. Structured comparison details will require representation in a separate CLUSTER archetype.Details about an image being compared to the image being reported.Comparison imageThis data element is redundant if the anatomical site is identified in the 'Test name'.Simple description about the physical place on, or in, the body that was imaged.Anatomical siteIf there is no availability of previous imaging and/or reports this should also be stated using this data element.Narrative descripition about the comparison of this image, or series of images, with previous similar examinations.Comparison with previousFor example: the nature of any limitations and their impact on interpretation.Narrative description about the quality of the examination.Imaging qualityThis data element has multiple occurrences to allow for more than one differential diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Imaging diagnosis' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in each Imaging examination result.Single word, phrase or brief description representing a possible condition or diagnosis.Imaging differential diagnosisThis data element has 0..* occurrences to allow for more than one recommendation and associated rationale. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request.Suggestion for further imaging, investigations and/or referral, and associated rationale.RecommendationPlain chest x-rayOBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT169069000CLUSTERtruefalsetrue0at0006Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Pleural effusionConsolidationPatchy shadowsInterstitial changesInfiltrationGround glass opacitiesCLUSTERtruefalsetrue0at0034Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location\.v1constraintELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0035at0036at0037CLUSTERtruefalsetrue0at0014falsefalsetruefalsetrue1openEHR-EHR-CLUSTER.imaging_finding.v0A single finding in an imaging examination.Imaging findingFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The presence or absence of the finding.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Presence?Additional narrative about the finding, not captured in other fields.Observation.noteNTE.3CommentAdditional structured detail about the finding.Structured detailCoding with an external terminology is strongly recommended.The name of the finding.Observation.codeOBX.3Finding nameNarrative description about the observed clinical finding.DescriptionNarrative description about the difference between a previous finding and the finding in this report.Comparison to previousThe finding is improving compared to previous imaging examinations.ImprovingThe finding is unchanged compared to previous imaging examinations.UnchangedThe finding is worsening compared to previous imaging examinations.WorseningSimple description of anatomical location.Anatomical locationStructured details about the location of the finding.Structured anatomical locationThe finding is observed in the image.PresentThe finding is not observed in the image.AbsentIt is not possible to determine if the finding is present or absent.IndeterminateELEMENTtruefalsetrue0at0020valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11No obvious signs of pneumoniaPresenting with pneumoniaCLUSTERtruefalsetrue0at0045Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0047itemstruetruefalsefalse01falsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11BaselineEVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0003itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT169069000CLUSTERtruefalsetrue0at0006Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0000itemstruetruefalsefalse11ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Pleural effusionConsolidationPatchy shadowsInterstitial changesInfiltrationGround glass opacitiesCLUSTERtruefalsetrue0at0034Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location\.v1constraintELEMENTtruefalsetrue0at0001valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0035at0036at0037CLUSTERtruefalsetrue0at0014ELEMENTtruetruefalsefalse01at0029valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11ImprovingUnchangedWorseningfalsefalsetruefalsetrue1openEHR-EHR-CLUSTER.imaging_finding.v0A single finding in an imaging examination.Imaging findingFor example '7.3 mmol/l', 'Raised'. The 'Any' data type will need to be constrained to an appropriate data type in a specialisation, a template or at run-time to reflect the actual analyte result. The Quantity data type has reference model attributes that include flags for normal/abnormal, reference ranges and approximations - see https://specifications.openehr.org/releases/RM/latest/data_types.html#_dv_quantity_class for more details.The presence or absence of the finding.Observation.value[x]OBX.2, OBX.5, OBX.6, OBX.7, OBX.8Presence?Additional narrative about the finding, not captured in other fields.Observation.noteNTE.3CommentAdditional structured detail about the finding.Structured detailCoding with an external terminology is strongly recommended.The name of the finding.Observation.codeOBX.3Finding nameNarrative description about the observed clinical finding.DescriptionNarrative description about the difference between a previous finding and the finding in this report.Comparison to previousThe finding is improving compared to previous imaging examinations.ImprovingThe finding is unchanged compared to previous imaging examinations.UnchangedThe finding is worsening compared to previous imaging examinations.WorseningSimple description of anatomical location.Anatomical locationStructured details about the location of the finding.Structured anatomical locationThe finding is observed in the image.PresentThe finding is not observed in the image.AbsentIt is not possible to determine if the finding is present or absent.IndeterminateELEMENTtruefalsetrue0at0020valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11No obvious signs of pneumoniaPresenting with pneumoniaCLUSTERtruefalsetrue0at0045Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1statetruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0047itemstruetruefalsefalse01falsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Follow upfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0025itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0041Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0026Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0046Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11CT ChestopenEHR-EHR-OBSERVATION.imaging_exam_result.v0Record the findings and interpretation of an imaging examination performed.Imaging examination result@ internal @Event SeriesDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @TreeCoding with a terminology, potentially a pre-coordinated term specifying both modality and anatomical location, is desirable where possible. Possible candidate terminologies: LOINC, SNOMED CT or RadLex.The name of the imaging examination or procedure performed.Test nameAlso known as 'Examination type'. For example: Ultrasound; Computed tomography; or X-ray. Coding with a terminology is desirable, where possible. If the modality is specified by a code in the Examination result name, then this field may be redundant.Type of equipment that originally acquired the image or series of images.ModalityIdentification of the anatomical site related to a specific finding will be recorded within each instance of CLUSTER.imaging_finding.Structured detail about the anatomical site related to the entire result.Structured anatomical siteThe status of the examination result as a whole.Overall result statusNarrative description of the clinical findings.FindingsNo result yet available.RegisteredThis is an initial or interim result: data may be missing or verification not been performed.InterimThe result is complete and verified by the responsible radiologist.FinalThe result has been modified subsequent to being Final, and is complete and verified by the radiologist.AmendedThe result is not available because the examination was not started or completed.Cancelled / AbortedThis may include a link to the clinical information provided in the original examination request. If other sources of clinical information have been used, this should be clearly stated using this data element.Description of clinical information available at the time of interpretation of results.Clinical information providedThis data element has multiple occurrences to allow for more than one diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Differential diagnoses' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in the each Imaging examination result.Single word, phrase or brief description representing the likely condition or diagnosis.Imaging diagnosisAlso referred to as 'Opinion' or 'Impression'.Narrative concise, clinically relevant interpretation of all imaging findings, and include a comparison with previous studies where appropriate.ConclusionFor example: a note that the film was given to the patient.Additional narrative about the examination not captured in other fields.CommentThe date and/or time that the result was issued for the recorded 'Examination result status'.DateTime result issued@ internal @TreeDemographic details about the receiving imaging service performing the imaging test.Receiving imaging serviceDetails concerning a single examination requested. Note: Usually there is one examination request for each result, however in some circumstances multiple examination requests may be represented using a single Imaging examination result archetype.Examination request detailsThe local identifier assigned to the order by the order requester. Equivalent to the HL7 Placer Order Identifier.Requester order identifierIdentification of imaging examination or procedure requested, where the examination requested differs from the examination actually performed.Examination requested nameDetails about the clinician or organisation requesting the imaging examination.RequesterThe local identifier assigned to the examination order by the order filler, usually by the Radiology Information System (RIS). Usually equivalent to the HL7 Filler Order Number.Receiver order identifierUnique identifier of this study allocated by the imaging service.DICOM study identifierThe local identifier given to the imaging examination report.Report identifierImages referred to, or provided, to assist clinical understanding of the examination. If attached image is in DICOM format, all the fields below should be populated so the values are available to software that does not process DICOM images.Image detailsUnique identifier of this image allocated by the imaging service (often the DICOM image instance UID).Image identifierUnique identifier of this series allocated by the imaging service.DICOM series identifierThe name of the imaging view e.g Lateral or Antero-posterior (AP). Coding using a terminology is desirable, where possible.ViewDescription of the subject of care's positon when the image was performed.PositionSpecific date/time the imaging examination was performed.Image DateTimeAn attached or referenced image of a current view.ImageAdditional structured details of technical details and procedure.Structured techniqueStructured details about each imaging finding.Imaging findingsDigital image or video representing the exam result.Image representationFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.Extension@ internal @TreeNarrative description of factors, not recorded elsewhere, that may influence the examination findings and/or result.Confounding factorsFor example: outline of technique; non-routine alternative or additional imaging; nature and route of administration of contrast agent, radiopharmaceuticals and/or treatments administered; adverse reactions to contrast media.Narrative description about the technical details and procedure.TechniqueDetails about the image being reported.Reported imageFor example: narrative description about progression/worsening of a condition. Structured comparison details will require representation in a separate CLUSTER archetype.Details about an image being compared to the image being reported.Comparison imageThis data element is redundant if the anatomical site is identified in the 'Test name'.Simple description about the physical place on, or in, the body that was imaged.Anatomical siteIf there is no availability of previous imaging and/or reports this should also be stated using this data element.Narrative descripition about the comparison of this image, or series of images, with previous similar examinations.Comparison with previousFor example: the nature of any limitations and their impact on interpretation.Narrative description about the quality of the examination.Imaging qualityThis data element has multiple occurrences to allow for more than one differential diagnoses. Coding with a terminology is preferred, where possible. This data element should be regarded as mutually exclusive to 'Imaging diagnosis' - only one of 'Differential diagnoses' OR 'Imaging diagnosis' should be present in each Imaging examination result.Single word, phrase or brief description representing a possible condition or diagnosis.Imaging differential diagnosisThis data element has 0..* occurrences to allow for more than one recommendation and associated rationale. Formal orders for additional imaging examination, investigation should be recorded using an INSTRUCTION archetype, such as INSTRUCTION.service_request.Suggestion for further imaging, investigations and/or referral, and associated rationale.RecommendationComputed tomography of chestfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Assessmentitemstruetruefalsefalse01OBSERVATIONtruetruefalsefalse01at0000datatruetruefalsefalse11HISTORYtruetruefalsefalse11at0001eventstruetruefalsefalse01EVENTtruetruefalsefalse01at0002datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0042itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0043valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT840546002CLUSTERtruefalsetrue0at0044itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0045valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Travel to an at risk locationReside in an at risk locationContact with an infected personContact with an at risk personELEMENTtruetruefalsefalse01at0046valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0047at0048at0049CLUSTERtruefalsetrue0at0054Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.family_prevalence\.v1constraintfalsefalsetruefalsetrue1falsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Last 14 daysfalsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0004itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0056Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11COVID-19 exposure assessmentopenEHR-EHR-OBSERVATION.exposure_assessment.v0Details about actual or potential exposure to a chemical, physical or biological agent which has caused or may cause harm to an individual.Exposure assessment@ internal @HistoryDefault, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.Any event@ internal @Item tree@ internal @Item treeCoding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: 2019-nCoV; or HIV.The name of the chemical, physical or biological agent to which an individual may have been exposed.ExposureDetails about each possible exposure risk factor.Per risk factorFor example: Travel to an 'at risk' location; or exposure to infected body fluids. Coding of 'Risk factor' with a terminology is preferred, where possible.The name of the exposure risk factor.Risk factorPresence of the exposure risk factor.PresenceExposure risk has been identified for this individual.PresentIt is not possible to determine if the exposure risk is present or absent.IndeterminateExposure risk has not been identified for this individual.AbsentNarrative description about the exposure risk.DescriptionThe date/time that the exposure risk was identified.Date identifiedIdentification of the path to the archetype or data node for the evidence of exposure.Link to evidenceFor example: Prevalence of the risk factor in family members.Structured detail about other aspects of the exposure risk factor assessment.DetailAdditional narrative about the exposure risk factor not captured in other fields.CommentFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.ExtensionExposure to severe acute respiratory syndrome coronavirus 2EVALUATIONtruetruefalsefalse01at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0002valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT840539006CLUSTERtruetruefalsefalse01at0016itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0013valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Presentation with fever and/or respiratory symptomsImaging consistent with COVID-19 pneumoniaEarly levels of leukocytes or lymphocytes normal or decreasedRT-PCR positive for COVID-19Gene sequencing highly homologous with COVID-19IgM and IGM positive for COVID-19nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Clinical factorELEMENTtruetruefalsefalse01at0017valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0018at0026at0019CLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.family_prevalence\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Clinical manifestationtruefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0010itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11CLUSTERtruefalsetrue0at0011Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11COVID-19 clinical assessmentopenEHR-EHR-EVALUATION.health_risk.v1Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.Health risk assessment@ internal @structureCoding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.Health riskThere may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.Evaluation of the health risk.Risk assessmentDetails that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.Justification for this risk assessment.Rationale@ internal @TreeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionIdentification of the path to the archetype or data node for the evidence of risk.Link to evidenceFor example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of
+'Risk factor' with a terminology, where possible.Identification of the risk factor, by name.Risk factorNarrative description about the risk factor.DescriptionAdditional narrative about the risk assessment not captured in other fields.CommentDetails about each possible risk factor.Risk factorsPresence of the risk factor.PresenceThe risk factor has been identified for this individual.PresentThe risk factor has not been identified for this individual.AbsentRecord of whether the risk assessment is a relative or absolute.Assessment typeRatio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.Relative riskRatio of probability of a health event or condition occurring compared to the population as a whole.Absolute riskThat is: the risk of experiencing the identified 'Health risk' in the next <X> years.The time period during which the predicted health risk is relevant.Time periodThis data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician.The date this health risk assessment was last updated.Last updatedFor example: Framingham cardiovascular risk calculator.Identification of the algorithm or guideline used to make the assessment of risk.Assessment methodIt is not possible to determine if the risk factor is present or absent.IndeterminateFor example: Prevalence of the risk factor in family members.Structured detail about other aspects of the risk factor assessment.DetailRecord as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated.The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.MitigatedThe date/time that the risk factor was identified.Date identifiedAdditional narrative about the risk factor not captured in other fields.CommentDisease caused by severe acute respiratory syndrome coronavirus 2SNOMED-CT52101004SNOMED-CT2667000SNOMED-CT82334004EVALUATIONtruetruefalsefalse01at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0002valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Risk of severe or critical diseaseCLUSTERtruetruefalsefalse01at0016itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0013valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Progressive decrease in lympocytes.Progressive increase in inflammatory biomarkers, including IL-6 and CRP.Progressive increase in lactic acid.Rapid progression of lung lesions.ELEMENTtruetruefalsefalse01at0017valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0018at0026at0019CLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.family_prevalence\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Adult risk factorsCLUSTERtruetruefalsefalse01at0016itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0013valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Increase in respiratory ratePoor mental reaction and drowsiness.Progressive increase in lactic acid.Infiltration on both sides or in multiple lobes on chest x-ray.Pleural effusion on chest x-ray.Rapid progression of lung lesions on chest x-ray.Underlying diseases (for example congenital heart disease, bronchopulmonary dysplasia, respiratory tract deformity, abnormal hemoglobin and sever malnutrition etc)Underlying immunodeficiency.ELEMENTtruetruefalsefalse01at0017valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0018at0026at0019CLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.family_prevalence\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Child risk factorstruefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0010itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0011Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Risk of severe and critical diseaseopenEHR-EHR-EVALUATION.health_risk.v1Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.Health risk assessment@ internal @structureCoding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.Health riskThere may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.Evaluation of the health risk.Risk assessmentDetails that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.Justification for this risk assessment.Rationale@ internal @TreeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionIdentification of the path to the archetype or data node for the evidence of risk.Link to evidenceFor example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of
+'Risk factor' with a terminology, where possible.Identification of the risk factor, by name.Risk factorNarrative description about the risk factor.DescriptionAdditional narrative about the risk assessment not captured in other fields.CommentDetails about each possible risk factor.Risk factorsPresence of the risk factor.PresenceThe risk factor has been identified for this individual.PresentThe risk factor has not been identified for this individual.AbsentRecord of whether the risk assessment is a relative or absolute.Assessment typeRatio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.Relative riskRatio of probability of a health event or condition occurring compared to the population as a whole.Absolute riskThat is: the risk of experiencing the identified 'Health risk' in the next <X> years.The time period during which the predicted health risk is relevant.Time periodThis data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician.The date this health risk assessment was last updated.Last updatedFor example: Framingham cardiovascular risk calculator.Identification of the algorithm or guideline used to make the assessment of risk.Assessment methodIt is not possible to determine if the risk factor is present or absent.IndeterminateFor example: Prevalence of the risk factor in family members.Structured detail about other aspects of the risk factor assessment.DetailRecord as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated.The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.MitigatedThe date/time that the risk factor was identified.Date identifiedAdditional narrative about the risk factor not captured in other fields.CommentSNOMED-CT52101004SNOMED-CT2667000SNOMED-CT82334004EVALUATIONtruefalsetrue0at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01CLUSTERtruefalsetrue1at0003itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0007valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Upper respiratory tract infectionsCOVID-19 pneumoniaOther viral pneumoniaMycoplasma pneumoniaVasculitisDermatomyositisCryptogenic organising pneumoniaELEMENTtruetruefalsefalse01at0004valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0015at0017DV_TEXTtruetruefalsefalse11CLUSTERtruefalsetrue0at0020Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.clinical_evidence\.v1constraintfalsefalsetruefalsetrue1truefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0018itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0019Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0openEHR-EHR-EVALUATION.differential_diagnoses.v0A list of one or more possible conditions or diagnoses that may be responsible for the clinical presentation, examination findings and test results.Differential diagnoses@ internal @TreeDetails about a single differential diagnosis.Differential diagnosisLikelihood of this diagnosis being present.LikelihoodAdditional narrative about all differential diagnoses, not captured in other fields.CommentNarrative description about the rationale for this diagnosis being included as a differential.RationaleName of the differential diagnosis.DiagnosisPossibly the diagnosis, but without a weight of supportive evidence.SuspectedLikely to be the working diagnosis, with good supportive evidence.Likely@ internal @Item treeFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.ExtensionDetails about clinical evidence supporting a differential diagnosis.Clinical evidenceAdditional narrative about a single differential diagnosis, not captured in other fields.Overall commentfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Treatmentitemstruetruefalsefalse01INSTRUCTIONtruetruefalsefalse01at0000activitiestruetruefalsefalse01ACTIVITYtruefalsetrue1at0001descriptiontruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0009itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0121valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT17049700622531600130535100443014700838476000430449500470780800142731400228178900423357300842831100840617009124000038906600140898000076334006386639001723688009171022008CLUSTERtruefalsetrue0at0151Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.service_direction(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.therapeutic_direction\.v1constraintCLUSTERtruefalsetrue0at0132Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0149Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0constraintCLUSTERtruefalsetrue0at0116Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0008itemstruetruefalsefalse01CLUSTERtruetruefalsefalse01at0141Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruetruefalsefalse01at0142Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0128Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.distribution\.v1constraintCLUSTERtruefalsetrue0at0112Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11TreatmentopenEHR-EHR-INSTRUCTION.therapeutic_activity_order.v0An order or instruction for a health-related therapy or activity to be carried out.Therapeutic activityCurrent Activity.Current Activity@ internal @Tree@ internal @TreeUsually equivalent to the HL7 Placer Order Identifier.The local identifier assigned by the requesting clinical system.Requester order identifierUsually equivalent to the HL7 Filler Order Identifier.The local identifier assigned to the request by the clinician or organisation receiving the request for therapy.Receiver order identifierThis data element allows for recording of the timing for a single therapy, either as a date and time, a date ranges or a text descriptor which can allow for 'next available. In practice, clinicians will often think in terms of ordering therapys as approximate timing, for example: review in 3 months, 6 months or 12 months. As clinical systems need more exact parameters to operate on, this '3 months' will usually be converted to an exact date 3 months from the date of recording and stored using this data element. If complex timing or sequences of timings are required, use the CLUSTER.service_direction archetype within the 'Complex timing' SLOT and this data element becomes redundant.The date/time, or acceptable interval of date/time, for provision of the therapy.Activityy dueCoding of the 'Reason for order' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required.A short phrase describing the reason for the order.Reason for orderNarrative description about the reason for request.Reason descriptionCoding of the 'Intent' with a coding system is desirable, if available. This data element allows multiple occurrences to enable the user to record a multiple responses, if required.Description of the intent for the order.IntentSpecific definitions of emergency and urgent will vary between clinical contexts, clinical systems and the nature of the request itself, so have not been defined in this archetype. If explicit timing is required then the Activity period should be clearly stated.Urgency of the order.UrgencyRecord as TRUE if additional information has been identified and will be forwarded when available. For example: pending test results.Supplementary information will be following the order.Supplementary informationDescription of the supplementary information.Information descriptionFor example: local information requirements; or additional metadata to align with FHIR.Additional information required to extend the model with local content or to align with other reference models or formalisms.ExtensionLanguage, transport or other personal requirements to support the patient's attendance or participation in carrying out the activity.Patient requirementsCoding of the 'Activity name' with a coding system is desirable, if available. For example: 'recommendation to rest in bed'; 'apply ice for 20 minutes every 2 hours'.The name of the single therapy or activity requested.Activity nameStatus is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information. Coding with a terminology is preferred, where possible.The status of the order for the activity as indicated by the requester.Order statusDetails of additional clinicians, organisations or agencies who require copies of any communication.Distribution listAdditional detail about the activity ordered.Specific detailsThis data point should be used to describe the named activity in more detail, including how it should be delivered, individual concerns and issues that might be encountered in carrying out the activity.Narrative description about the activity ordered.DescriptionThe request requires immediate attention.EmergencyThe request requires prioritised attention.UrgentThe request does not require prioritised scheduling.RoutineDetails about the clinician or organisation requesting the therapy.RequesterDetails about the clinician or organisation receiving the request for therapy.ReceiverThis date/time is the equivalent to the latest possible date for carrying out the activity or to the date of expiry for this order. For example: an activity may be required to be completed before another event, such as scheduled surgery.The date/time that marks the conclusion of the clinically valid period of time for carrying out this activity.Activity period expiryThis date/time is the equivalent to the earliest possible date for carrying out the activity. For example: sometimes a certain amount of time must pass before an activity can be carried out. For example: 'start mobilisation 2 days post surgery'.The date/time that marks the beginning of the valid period of time for delivery of this activity.Activity period startRecord as TRUE to record explicity that the order has no expiry date. For example: required for a lifelong activity.The valid period for this order is open ended and has no date of expiry.Indefinite?Coding of the 'Activity type' with a coding system is desirable, if available. If the 'Therapy name' was coded, it is possible for this data point to be derived from the code. For example: 'Self-care intervention'.Category of therapy or activity ordered.Activity typeDigital document, image, video or diagram supplied as additional information to support or inform the order.Supporting informationAdditional narrative about the activity order not captured in other fields.CommentDetails about a complex order requiring a sequence of timings.Complex timingCoding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. For example: 'Sprained ankle' or 'Type 1 Diabetes mellitus'.The clinical reason for the ordered therapy.Clinical indicationIsolation because of infectionBedrestAdmission to intensive care unitFluid balance monitoringFeeding and dietry regimeVital signs monitoringOxygen therapy supportAntiviral therapyAntibiotic therapyExtracorporeal membrane oxygenationNon-invasive ventilationMechanical ventilationProne body positionCirculatory careRenal careImmunotherapyTermination of pregnancyTraditional Chinese Medicine therapyPsychological counsellingINSTRUCTIONtruetruefalsefalse01at0000activitiestruetruefalsefalse01ACTIVITYtruefalsetrue0at0001descriptiontruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0002itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0070valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT4575400938706700338689600938718800511659300353136009419933005444648007116648000CLUSTERtruetruefalsefalse01at0143Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.medication(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruefalsetrue0at0091valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11CLUSTERtruetruefalsefalse01at0093Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0095Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0177Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.therapeutic_direction(-[a-zA-Z0-9_]+)*\.v1constraintBoolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintELEMENTtruefalsetrue0at0018valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11CLUSTERtruefalsetrue0at0069Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.medication_authorisation(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.medication_authorisation(-[a-zA-Z0-9_]+)*\.v1constraintCLUSTERtruefalsetrue0at0166Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constrainttruefalsetruefalsetrue1falsefalsetruefalsetrue0protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0005itemstruetruefalsefalse01CLUSTERtruefalsetrue0at0008Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Medication recommendationopenEHR-EHR-INSTRUCTION.medication_order.v2An order for a medication, vaccine, nutritional product or other therapeutic item for an identified individual.Medication orderDetails of the requested order.Order@ internal @TreeThis data element allows for multiple occurrences to be defined more explicitly at run-time, if required.Unique identifier for the medication order.Order identifierThe amount and units of the medication, vaccine or other therapeutic good to be used or administered at one time.Dose amount descriptionFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionThis narrative should normally subsume data captured in 'Dose amount', 'Dose timing' and any additional instructions for use. Where the medication dose directions are fully carried by the structured, computable dose directions, this element should carry the narrative equivalent, generally auto-generated. If it is not possible to represent the intended 'Dose direction' fully in computable form, partial representation is not recommended, and the directions should be only recorded in narrative form using this data element.Complete narrative description about how the ordered item is to be used.Overall directions descriptionFor example: 'Start if symptoms recur'. This is intended for a general pre-condition which should trigger the whole medication course to be started, and not for 'as required' administrations of an ongoing order.A condition which, when met, requires the commencement of administration or use.Order start criterionThe date and optional time to commence use of the ordered item.Order start date/timeThe date and optional time when it is planned to cease use of the ordered item.Order stop date/timeFor example: 'Stop after symptoms disappear''.A condition which, when met, requires the cessation of administration or use.Order stop criterionFor example: 'Angina'. Coding of the clinical indication with a terminology is preferred, where possible. This data element allows multiple occurrences. It is not intended to carry an indication for administrative authorisation purposes.The clinical reason for use of the ordered item.Clinical indicationFor example: precautions as 'take with food', 'Avoid grapefruit', 'Dissolve in water', 'store in a cool, dry place'. This data element allows multiple occurrences and should be coded with a reference terminology, where possible.An additional instruction on how to use or store the ordered item.Additional instructionGenerally this is only used when passing information between legacy systems. For example: '10mg bd; 20mg n' as used by the NHS Dose syntax (in development).A parsable, computable text representation of the directions.Parsable directionsFor example: To record that the patient had been taking antibiotics 3 days prior to hospital admission, in the context of a 7 day course.The time period during which the individual/patient has already been using the ordered item as a part of the intended whole order but prior to the issuance of this order.Duration of order completedFor example: 'up to 1gram per day'. This cluster allows multiple occurrences to enable representation of multiple maximum doses that apply to different time periods. Lifetime maximum dose should not be carried here as it refers to multiple orders over time.Details about the maximum, cumulative dose allowed over a defined period for the ordered item.Maximum doseExample: 24 hours.The period of time during which the maximum dose is calculated.Allowed periodFor example: To record that the patient has taken the two first antibiotic tablets of a three day course, prior to discharge from the hospital to a nursing home.The number of administrations of the ordered item that have been completed, as part of the intended whole order but prior to the issuance of this order.Administrations completedDetails about medication safety for the ordered item.Medication safetyConfirmation by the prescriber that the normal dose or other safety limit has been overridden due to exceptional circumstances.Exceptional safety override?This SLOT allows for local variation in the different jurisdictions regarding medication dispensing amount to be managed.Details about the amount of the ordered item to be dispensed.Dispense amountFor example: details of repeat/refill supply. This SLOT allows for local variation in the different jurisdictions regarding medication authorisation and re-authorisation to be managed.Details of authorisation of the ordered item, including supporting local self-administration, issue and endorsement policies.Authorisation directionsDepending on the prescribing context this field could be used for either generic- or product-based prescribing. This data field can be used to record tightly bound orders of different medications when they are prescribed as a single pack. It is strongly recommended that the 'Medication item' be coded with a terminology capable of triggering decision support, where possible. The extent of coding may vary from the simple name of the medication item through to structured details about the actual medication pack to be used. Free text entry should only be used if there is no appropriate terminology available.Name of the medication, vaccine or other therapeutic/prescribable item being ordered.Medication itemFor example: 'oral', 'intravenous', or 'topical'.
+Coding of the route with a terminology is preferred, where possible. Multiple potential routes may be specified.The route by which the ordered item is to be administered into the subject's body.RouteFor example: 'left upper arm', 'intravenous catheter right hand'.
+ Coding of the body site with a terminology is preferred, where possible.Name of the site of administration of the ordered item.Body siteStructured description of the site of administration of the ordered item.Structured body siteFor example: ' via Z-track injection'; 'via nebuliser'. Coding of the method with a terminology is preferred, where possible.The technique or device by which the ordered item is to be administered.Administration methodDetails of the medical device used to assist administration of the ordered item.Administration deviceFor example: 'To reduce your blood pressure', 'To thin your blood'. This data element allows multiple occurrences and should be coded with a reference terminology, where possible. If required it is possible to use a LINK attribute to associate this element with, for example, the 'original diagnosis' in a separate Problem list composition but the indication should be explicitly recorded here, as the link target may change over time.An additional instruction directed primarily at the individual/patient or carers.Patient informationExample: Detailed instructions for phased dispensing of opiates.An additional instruction directed primarily at the person dispensing the ordered item.Dispense instructionFor example: 'Please check renal function in 2 weeks'. This data element allows multiple occurrences.An additional instruction which gives advice on recommended or required monitoring of the ordered item.Monitoring instructionCourse summary may be required when transmitting medication information between systems or representing a FHIR Medication statement. For example: as part of a referral, emergency patient summary or discharge communication.Summary information about use of the ordered item, such as current status or key dates, generally used in non-prescription contexts.Order summaryDetails about the whole medication order.Order detailsDirections about the dispensing of the ordered item.Dispense directionsFor example: 1, 1.5, 0.125.The maximum, cumulative amount of medication which should be administered within the allowed period. The unit for this amount is carried in Maximum amount unit.Maximum amountIn many jurisdictions, substitution of an ordered item as a generic form or with a different brand name, which has been determined as bioequivalent, is allowed at the point of dispense or supply. In other cases substitution is assumed and the clinician has to explicitly request non-substitution.Permission for substitution with a bioequivalent item.Substitution directionFor example 'Urgent'. This is left to be templated or specialised according to local valuesets. Some jurisdictions allow instructions to dispense to be marked as 'urgent' so that the dispensary handles them quickly.An indicator of the urgency with which the ordered item should be dispensed.PriorityUse this SLOT where the detailed description of the ordered item needs to be explicitly stated. For example: the form, strength, any diluents or mixture of ingredients.Structured details about the overall preparation including strength, form and constituent substances.Preparation detailsFor example: 'tablet','mg'. Coding of the dose unit with a terminology is preferred, where possible.The unit for the maximum amount allowed.Maximum amount unitFor example: 'pain relief'; 'palliative care'; 'low-dose prophylaxis'; 'rehydration'; 'nutritional infusion'.The overall therapeutic intent of the ordered item.Therapeutic intentThe total daily dose records the expected effective dose, and thus support titration of an initial low dose towards the effective dose over a period of time. This is not itself the target dose or goal but the actual effective daily dose against that goal. In some circumstances the Total daily dose will be calcuable from computable directions, in others it may need to be manually entered.Details about the total daily amount of the ordered item expected to be administered.Total daily effective doseFor example '20mg'.The amount of ordered item which will be taken each day if administered as intended.Total daily amountThe dose units are normally scientific units such as mg, ml rather than 'tablets'.The dose unit associated with the total daily amount.Total daily amount unitFor example 'Generic preparation not bio-equivalent'.The reason why an ordered item should not be substituted at dispense.Non-substitution reasonMay be used to control the time of dispensing of medications with potential for abuse. For example: benzodiazepines or analgesics.The date from which the ordered item is permitted to be dispensed for the first time.Dispensing start dateIn some jurisdictions, orders to dispense may have an expiry date after which the prescription may not be dispensed.The date after which the ordered item is no longer valid to be legally dispensed.Dispensing expiry dateFor example: 'Not responsive at maximum recommended dose. Critical situation.', 'Peniciilin is only valid treatment, likelihood of true penicillin allergy is low'.The reason for a clinical safety or maximum dose override.Override reasonFor example: 'Hypertension control', 'Target dose 20mg daily'. The description could be used to identify a name, phrase or paragraph about the purpose for recording total daily effective dose, commonly to allow to titration towards a specific target dose.
+The goal or target dose might be recorded here or more commonly as part of a linked EVALUATION 'Goal' archetype.Description of the reason for recording a total daily effective dose.PurposeAdditional structured details about the ordered item not captured in other fields.Additional detailsAdditional narrative about the medication order not captured in other fields.CommentSubstitution of the medication with a bioequivalent medication is allowed.PermittedSubstitution of the medication with a bioequivalent medication is not allowed.Not permittedThis SLOT allows for local variation in the different jurisdictions regarding medication dispensing.Further details related to dispense directions.Dispense detailsFor example: 'Allergic to penicillin', 'Atenolol duplicated'.A known or recognised safety issue which applies to this subject and the ordered item, such as an allergy, drug duplication warning or contraindication. This element is normally only recorded when this safety advice is overridden.Overriden safety adviceIn some settings, it is common to split overall narrative directions into more specific segments of narrative. For example in hospital settings, it can be common to split the overall directions into 'Dose amount' and 'Dose timing', both as narrative text. These terms can be applied at template or run-time.A narrative description of a specific part of overall directions.Specific directions descriptionFor example: 'Adjusted for amputation'.A description of the justification used to calculate a dose amount or administration rate where this is dependent on some other factor.Dosage justificationDetails of structured dose and timing directions.Structured dose and timing directionsOverriding of a known or recognised safety issue which applies to this subject and the ordered item, such as an allergy, drug duplication warning or contraindication.Safety overrideInterferon alfaLopinavirRitonavirRibavirinMethylprednisoloneChloroquine phosphateGlucocorticoidTocilizumabGamma globulinfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Dischargeitemstruetruefalsefalse01EVALUATIONtruetruefalsefalse01at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0002valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED-CT428483004CLUSTERtruetruefalsefalse01at0016itemstruetruefalsefalse11ELEMENTtruetruefalsefalse11at0013valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Body temperature normal for more than 3 daysRespiratory symptoms improvedChest x-ray shows absorption of inflammationNucleic acid tests negative on 2 consecutive samples, at least 24 hours apartnametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11FactorELEMENTtruetruefalsefalse01at0017valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0018at0026at0019CLUSTERtruefalsetrue0at0027Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.family_prevalence\.v1constraintfalsefalsetruefalsetrue1nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Clinical factorsELEMENTtruetruefalsefalse01at0003valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Fit for dischargeNot fit for dischargenametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Discharge assessmenttruefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0010itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0024valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11CLUSTERtruefalsetrue0at0011Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Discharge criteriaopenEHR-EHR-EVALUATION.health_risk.v1Assessment of the potential and likelihood of future adverse health effects as determined by identified risk factors.Health risk assessment@ internal @structureCoding of 'Health risk' with a terminology is preferred, where possible. Free text should be used only if there is no appropriate terminology available. For example: risk of cardiovascular disease, with risk factors of hypertension and hypercholesterolaemia.Identification of the potential future disease, condition or health issue for which the risk is being assessed, by name.Health riskThere may be multiple variations on the assessment of risk. The Choice data type allows for recording of the assessment as either free text or value sets (such as low, medium or hig). The proportion data type allows recording of a percentage, a ratio or a fraction. The quantity data type allows recording of a decimal number.Evaluation of the health risk.Risk assessmentDetails that may be added to this data element may include information about the population subgroups etc against which the determination of risk is assessed.Justification for this risk assessment.Rationale@ internal @TreeFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionIdentification of the path to the archetype or data node for the evidence of risk.Link to evidenceFor example: hypertension and hypercholesterolaemia, which may be used as part of the overall assessment for cardiovascular disease; or a genetic marker. Coding of
+'Risk factor' with a terminology, where possible.Identification of the risk factor, by name.Risk factorNarrative description about the risk factor.DescriptionAdditional narrative about the risk assessment not captured in other fields.CommentDetails about each possible risk factor.Risk factorsPresence of the risk factor.PresenceThe risk factor has been identified for this individual.PresentThe risk factor has not been identified for this individual.AbsentRecord of whether the risk assessment is a relative or absolute.Assessment typeRatio of probability of a health event or condition occurring compared to a population with similar characteristics eg same age and sex.Relative riskRatio of probability of a health event or condition occurring compared to the population as a whole.Absolute riskThat is: the risk of experiencing the identified 'Health risk' in the next <X> years.The time period during which the predicted health risk is relevant.Time periodThis data element may be thought redundant if the data is recorded and stored using COMPOSITIONs within a closed clinical system. However if this information is extracted from its original COMPOSITION context, for example, to be included in another document or message then the temporal context is effectively removed. This 'Last updated' data element has been explicitly added to allow the critical temporal data to be kept alongside the clinical data in all circumstances. It is assumed that the clinical system can copy the date from the COMPOSITION to reduce the need for duplication of data entry by the clinician.The date this health risk assessment was last updated.Last updatedFor example: Framingham cardiovascular risk calculator.Identification of the algorithm or guideline used to make the assessment of risk.Assessment methodIt is not possible to determine if the risk factor is present or absent.IndeterminateFor example: Prevalence of the risk factor in family members.Structured detail about other aspects of the risk factor assessment.DetailRecord as True if the risk factor has been treated or investigated and risk from this risk factor is considered to be lessened. For example: an infant given gentamicin in neonatal intensive care is regarded as having a risk of permanent hearing loss. If diagnostic testing shows no evidence of hearing loss in the first year of life, the risk of later hearing loss is considered to be much reduced, but still possible. This data element allows clinicians to say that the risk has been mitigated but should still be considered as a possibility in future. In practice, the risk factor could be maintained in the risk assessment in case it might impact the individual's health at a future time, but flagging that its contribution to risk calculation may not be as great as if it had not been previously treated or investigated.The risk factor has been identified as present, but then subsequently been mitigated by treatment or investigation.MitigatedThe date/time that the risk factor was identified.Date identifiedAdditional narrative about the risk factor not captured in other fields.CommentMedically fit for dischargeSNOMED-CT52101004SNOMED-CT2667000SNOMED-CT82334004falsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingSECTIONtruetruefalsefalse01at0000nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Conclusionitemstruetruefalsefalse01EVALUATIONtruetruefalsefalse01at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0002valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11SNOMED_CT882784691000119100674814021000119106880529761000119102138389411000119105866151004866152006CLUSTERtruefalsetrue0at0039Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11MildModerateSevereCriticalCLUSTERtruefalsetrue0at0043Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0046Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0032itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0070valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11COVID-19 diagnosisopenEHR-EHR-EVALUATION.problem_diagnosis.v1Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.Problem/Diagnosis@ internal @structureCoding of the name of the problem or diagnosis with a terminology is preferred, where possible.Identification of the problem or diagnosis, by name.Problem/Diagnosis namePartial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.Date/time clinically recognisedIf severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.An assessment of the overall severity of the problem or diagnosis.SeverityUse to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.Narrative description about the problem or diagnosis.Clinical descriptionCoding of the name of the anatomical location with a terminology is preferred, where possible.
+Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.Identification of a simple body site for the location of the problem or diagnosis.Body sitePartial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.Date/time of resolution@ internal @TreeUse this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations.
+
+If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.A structured anatomical location for the problem or diagnosis.Structured body siteMay include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.Details that are additionally required to record as unique attributes of this problem or diagnosis.Specific detailsUse status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.StatusThe problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.MildThe problem or diagnosis causes interference with normal activity or will damage health if left untreated.ModerateThe problem or diagnosis prevents normal activity or will seriously damage health if left untreated.SevereAdditional narrative about the problem or diagnosis not captured in other fields.CommentThe date this problem or diagnosis was last updated.Last updatedFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionNarrative description about the course of the problem or diagnosis since onset.Course descriptionThe level of confidence in the identification of the diagnosis.Diagnostic certaintyThe diagnosis has been identified with a low level of certainty.SuspectedThe diagnosis has been identified with a high level of certainty.ProbableThe diagnosis has been confirmed against recognised criteria.ConfirmedData captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.Date/time of onsetPneumonia caused by SARS-CoV-2Acute respiratory distress syndrome caused by SARS-CoV-2Lower respiratory infection caused by SARS-CoV-2Acute bronchitis caused by SARS-CoV-2Lymphocytopenia associated with severe acute respiratory syndrome coronavirus 2Thrombocytopenia associated with severe acute respiratory syndrome coronavirus 2EVALUATIONtruetruefalsefalse01at0000datatruetruefalsefalse11ITEM_TREEtruetruefalsefalse11at0001itemstruetruefalsefalse01ELEMENTtruetruefalsefalse11at0002valuetruetruefalsefalse01DV_TEXTtruetruefalsefalse11CLUSTERtruefalsetrue0at0039Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.anatomical_location(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.anatomical_location_clock(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.anatomical_location_relative(-[a-zA-Z0-9_]+)*\.v1constraintELEMENTtruetruefalsefalse01at0005valuetruetruefalsefalse01DV_CODED_TEXTtruetruefalsefalse11defining_codetruetruefalsefalse11CODE_PHRASEtruetruefalsefalse11localat0047at0048at0049DV_TEXTtruetruefalsefalse11CLUSTERtruefalsetrue0at0043Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintCLUSTERtruefalsetrue0at0046Boolean2007falseStringarchetype_id/valueattributeC_STRINGopenEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.problem_qualifier(-[a-zA-Z0-9_]+)*\.v1constraintfalsefalsetruefalsetrue1protocoltruetruefalsefalse01ITEM_TREEtruetruefalsefalse11at0032itemstruetruefalsefalse01ELEMENTtruetruefalsefalse01at0070valuetruetruefalsefalse01DV_DATE_TIMEtruetruefalsefalse11CLUSTERtruefalsetrue0at0071Boolean2007falseStringarchetype_id/valueattributeC_STRING.*constraintfalsefalsetruefalsetrue0nametruetruefalsefalse11DV_TEXTtruetruefalsefalse11valuetruetruefalsefalse11STRINGtruetruefalsefalse11Other diagnosisopenEHR-EHR-EVALUATION.problem_diagnosis.v1Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual.Problem/Diagnosis@ internal @structureCoding of the name of the problem or diagnosis with a terminology is preferred, where possible.Identification of the problem or diagnosis, by name.Problem/Diagnosis namePartial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of clinical recognition" should be converted to a date using the subject's date of birth.Estimated or actual date/time the diagnosis or problem was recognised by a healthcare professional.Date/time clinically recognisedIf severity is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant. Note: more specific grading of severity can be recorded using the Specific details SLOT.An assessment of the overall severity of the problem or diagnosis.SeverityUse to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.Narrative description about the problem or diagnosis.Clinical descriptionCoding of the name of the anatomical location with a terminology is preferred, where possible.
+Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.Identification of a simple body site for the location of the problem or diagnosis.Body sitePartial dates are acceptable. If the subject of care is under the age of one year, then the complete date or a minimum of the month and year is necessary to enable accurate age calculations - for example, if used to drive decision support. Data captured/imported as "Age at time of resolution" should be converted to a date using the subject's date of birth.Estimated or actual date/time of resolution or remission for this problem or diagnosis, as determined by a healthcare professional.Date/time of resolution@ internal @TreeUse this SLOT to insert the CLUSTER.anatomical_location or CLUSTER.relative_location archetypes if the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations.
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+If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, use of this SLOT becomes redundant.A structured anatomical location for the problem or diagnosis.Structured body siteMay include structured detail about the grading or staging of the diagnosis; diagnostic criteria, classification criteria or formal severity assessments such as Common Terminology Criteria for Adverse Events.Details that are additionally required to record as unique attributes of this problem or diagnosis.Specific detailsUse status or context qualifiers with care, as they are variably used in practice and interoperability cannot be assured unless usage is clearly defined with the community of use. For example: active status - active, inactive, resolved, in remission; evolution status - initial, interim/working, final; temporal status - current, past; episodicity status - first, new, ongoing; admission status - admission, discharge; or priority status - primary, secondary.Structured details for location-, domain-, episode- or workflow-specific aspects of the diagnostic process.StatusThe problem or diagnosis does not interfere with normal activity or may cause damage to health if left untreated.MildThe problem or diagnosis causes interference with normal activity or will damage health if left untreated.ModerateThe problem or diagnosis prevents normal activity or will seriously damage health if left untreated.SevereAdditional narrative about the problem or diagnosis not captured in other fields.CommentThe date this problem or diagnosis was last updated.Last updatedFor example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local content or to align with other reference models/formalisms.ExtensionNarrative description about the course of the problem or diagnosis since onset.Course descriptionThe level of confidence in the identification of the diagnosis.Diagnostic certaintyThe diagnosis has been identified with a low level of certainty.SuspectedThe diagnosis has been identified with a high level of certainty.ProbableThe diagnosis has been confirmed against recognised criteria.ConfirmedData captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed.Date/time of onsetfalsefalsetruefalsetrue0openEHR-EHR-SECTION.adhoc.v1A generic section header which should be renamed in a template to suit a specific clinical context.Ad hoc headingfalsefalsetruefalsetrue0openEHR-EHR-COMPOSITION.encounter.v1COVID-19 Pneumonia Diagnosis and Treatment (7th edition)Interaction, contact or care event between a subject of care and healthcare provider(s).Encounter@ internal @Treee.g. Local hospital departmental infomation or additional metadata to align with FHIR or CIMI equivalents.Additional information required to capture local context or to align with other reference models/formalisms.Extension
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