operationaltemplate.ErrorTest.opt Maven / Gradle / Ivy
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en
2022-02-10
unmanaged
1.0.0
Archetype Designer v1.23.8, user=90384840@github, repositoryId=etl-work-1go
ISO_639-1
en
Not Specified
3ce01ad0-0a5c-49cb-815d-e07b4c1c548f
ErrorTest
ErrorTest
COMPOSITION
true
true
false
false
1
1
at0000
category
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true
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1
1
false
DV_CODED_TEXT
true
true
false
false
1
1
defining_code
true
true
false
false
1
1
false
CODE_PHRASE
true
true
false
false
1
1
openehr
433
context
true
true
false
false
0
1
false
EVENT_CONTEXT
true
true
false
false
1
1
other_context
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true
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0
1
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ITEM_TREE
true
true
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1
1
at0001
items
true
true
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0
1
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ELEMENT
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1
at0002
value
true
true
false
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1
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DV_TEXT
true
true
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1
1
CLUSTER
true
false
false
true
0
at0006
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
content
true
true
false
false
0
1
false
OBSERVATION
true
true
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false
0
1
at0000
data
true
true
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false
1
1
false
HISTORY
true
true
false
false
1
1
at0001
events
true
true
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false
0
1
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EVENT
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false
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0
at0002
data
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1
1
false
ITEM_TREE
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1
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at0003
items
true
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0
1
false
ELEMENT
true
true
false
false
1
1
at0005
value
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0
1
false
DV_TEXT
true
true
false
false
1
1
CLUSTER
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true
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0
1
at0000
items
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1
1
false
ELEMENT
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1
at0034
value
true
true
false
false
0
1
false
DV_DATE_TIME
true
true
false
false
1
1
CLUSTER
true
false
false
true
0
at0027
archetype_id/value matches {/openEHR-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_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-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_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0013
archetype_id/value matches {/openEHR-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_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-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_]+)*\.v1
constraint
ELEMENT
true
true
false
false
0
1
at0015
value
true
true
false
false
0
1
false
DV_DATE_TIME
true
true
false
false
1
1
DV_INTERVAL<DV_DATE_TIME>
true
true
false
false
1
1
lower
true
true
false
false
0
1
false
DV_DATE_TIME
true
true
false
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1
1
upper
true
true
false
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0
1
false
DV_DATE_TIME
true
true
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1
1
CLUSTER
true
false
false
true
0
at0071
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0083
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0085
archetype_id/value matches {/openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_container(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0068
archetype_id/value matches {/openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.specimen_preparation(-[a-zA-Z0-9_]+)*\.v0
constraint
CLUSTER
true
false
false
true
0
at0093
archetype_id/value matches {/openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.specimen_transport(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0096
archetype_id/value matches {/openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.multimedia(-[a-zA-Z0-9_]+)*\.v0
constraint
false
false
true
false
false
true
1
openEHR-EHR-CLUSTER.specimen.v1
Laboratory specimen identifier
A unique identifier of the specimen, normally assigned by the laboratory.
Sometimes 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.
Parent specimen identifier
Unique identifier of the parent specimen, where the specimen is split into sub-samples.
For example: A specific histology slide specimen can have a specific paraffin wax block as its parent specimen.
Hazard warning
Identified health risk or biohazard to the collector or laboratory staff due to exposure to, or contact with, the specimen.
For example: 'Hepatitis B'; "nerve agent'. Coding of the 'Hazard warning' with a terminology is preferred, where possible.
Collection method
The method of collection used.
For 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.
Sampling context
The context in which the specimen is collected.
For 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.
Structured source site
A structured description of the area of the body from where the specimen is collected.
Utilise 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.
Collection date/time
The date and time that collection has been ordered to take place or has taken place.
This 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.
Physical properties
Physical dimensions, mass or non-measurable properties of the specimen.
For 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.
Specimen type
The type of specimen.
For example: Venous blood, bacterial culture, cytology, or tissue sample. Coding of the specimen type with a terminology is preferred, where possible.
Date/time received
The date and time that the sample was received at the laboratory.
Adequacy for testing
Information about whether the specimen was adequate for testing.
This 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.
Specimen quality issue
A specific quality issue with a specimen.
Coding of the specimen quality issues with a terminology is preferred, where possible.
Comment
Additional narrative about the specimen not captured in other fields.
Haemolysed
The specimen was haemolysed.
Lipaemic
The specimen was lipaemic.
Incorrect additive
An incorrect additive such as a transport medium or preservative was added to the specimen.
Insufficient amount
The available amount of specimen was insufficient to undertake the examination.
Satisfactory
The specimen is of sufficient quality to allow reporting.
Unsatisfactory - analysed
The specimen is unsatisfactory but has been analysed.
Unsatisfactory - not analysed
The specimen is unsatisfactory and has not been analysed.
Collection setting
Identification of the physical setting in which the specimen is collected.
For 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.
Processing details
Structured details about preparation or processing of the specimen.
For example: Staining or fixation.
Specimen collector identifier
Identifier of the person or organisation responsible for collecting the specimen.
This element is intended to be used where the specimen has already been collected and the actual collector is known.
Specimen collector details
The person or organisation responsible for collecting the specimen.
Collection description
Narrative description about the collection of the specimen.
Number of containers
The total number of physical units holding this specimen.
For example: Number of buckets, jars, vials, tubes, blocks, slides or grids.
Additional collection details
Addtional details related to specific collection methods.
For example details about needle biopsies in prostate cancer, where both the request and reporting about the specimen are detailed and specific.
Container details
Details about containers used.
Source site
Identification of the body site or other location from where the specimen is collected.
For 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.
External identifier
A unique identifier of the specimen, assigned by a party external to the laboratory.
For example: 'Requester ID', 'Archive ID, 'Biobank ID'.
Icteric
The specimen was icteric.
Handling error
An error arose when handling the specimen. For example: Incorrect storage, broken container.
Age
The specimen was too old to analyse or to analyse accurately.
Technical failure
The specimen could not be analysed for technical reasons.
Transport details
Structured details about transport of the specimen.
Clotted
The specimen was clotted.
Incorrectly labelled
The specimen was labelled incorrectly.
Digital representation
Structured details about a digital representation of the specimen.
For example the scanned image of a histopathology slide.
Specimen
A physical sample collected from, or related to, an individual for the purpose of investigation, examination or analysis.
For example: Tissue or body fluid.
CLUSTER
true
false
false
true
0
at0097
archetype_id/value matches {/openEHR-EHR-CLUSTER\.laboratory_test_analyte(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.laboratory_test_analyte(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v0|openEHR-EHR-CLUSTER\.laboratory_test_panel(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0122
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0118
archetype_id/value matches {/openEHR-EHR-CLUSTER\.media_capture(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.media_capture(-[a-zA-Z0-9_]+)*\.v0/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.media_capture(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.media_capture(-[a-zA-Z0-9_]+)*\.v0
constraint
false
false
true
false
false
true
1
state
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0112
items
true
true
false
false
0
1
false
CLUSTER
true
false
false
true
0
at0114
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
false
false
true
false
false
true
1
protocol
true
true
false
false
0
1
false
ITEM_TREE
true
true
false
false
1
1
at0004
items
true
true
false
false
0
1
false
CLUSTER
true
true
false
false
0
1
at0017
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
CLUSTER
true
false
false
true
0
at0110
archetype_id/value matches {/openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
openEHR-EHR-CLUSTER\.device(-[a-zA-Z0-9_]+)*\.v1
constraint
CLUSTER
true
false
false
true
0
at0117
archetype_id/value matches {/.*/}
Boolean
2007
false
String
- archetype_id/value
attribute
String
-
.*
constraint
false
false
true
false
false
true
0
openEHR-EHR-OBSERVATION.laboratory_test_result.v1
Event Series
@ internal @
Any event
Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Tree
@ internal @
Tree
@ internal @
Test name
Name of the laboratory investigation performed on the specimen(s).
A 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)'.
Receiving laboratory
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.
This 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.
Distribution list
Details of additional clinicians or organisations who require a copy of the test result.
The 'Distribution list' is for information-only, and that the primary recipient of the report is the person intended to act on the information.
Partial
This is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.
Final
The Test result is complete and verified by an authorised person.
Amended
The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.
Conclusion
Narrative description of the key findings.
For 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'.
Requester order identifier
The local identifier assigned by the requesting clinical system.
Equivalent to the HL7 Placer Order Identifier.
Receiver order identifier
The local identifier assigned to the test order by the order filler, usually by the Laboratory Information System (LIS).
Assigning 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.
Specimen detail
Details about the physical substance that has been analysed.
If 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.
Laboratory internal identifier
A local identifier assigned by the receiving Laboratory Information System (LIS) to track the test process.
This identifier is an internal tracking number assigned by the LIS, and it not intended to be the name of the test.
Overall test status
The status of the laboratory test result as a whole.
The 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.
Cancelled
The result is unavailable because the test was not started or not completed (also sometimes called 'aborted').
Overall test status timestamp
The date and/or time that ‘Overall test status’ was issued.
Diagnostic service category
The diagnostic service or discipline that is responsible for the laboratory test result.
This 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.
Requester
Details of the clinician or organisation requesting the laboratory test result.
Test request details
Details about the test request.
In 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'.
Test result
Results of the test performed on the specimen(s).
This SLOT may carry an individual analyte, a group, panel or battery of multiple analytes, or a more complex and specific structure.
Test diagnosis
Single word, phrase or brief description that represents the clinical meaning and significance of the laboratory test result.
For 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'.
Clinical information provided
Description of clinical information available at the time of interpretation of results.
This data element may include a link to the original clinical information provided in the test request.
Comment
Additional narrative about the test result not captured in other fields.
Original test requested name
Name of the original laboratory test requested.
This data element is to be used when the test requested differs from the test actually performed by the laboratory.
Registered
The existence of the test is registered in the Laboratory Information System, but there is nothing yet available.
Testing details
Structured details about the method of analysis, device or interpretation used.
For example: 'details of ELISA/nephelometry'.
Point-of-care test
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.
True if the test was performed directly at Point-of-Care (POCT).
Tree
@ internal @
Confounding factors
Issues or circumstances that impact on the accurate interpretation of the measurement or test result.
'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.
Structured confounding factors
Details of issues or circumstances that impact on the accurate interpretation of the measurement or test result.
For example: Last Normal Menstrual Period (LNMP).
Corrected
The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist. This is a sub-category of 'Amended'.
Entered in error
The Test Result has been withdrawn following previous Final release.
Extension
Additional information required to capture local content or to align with other reference models/formalisms.
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
Multimedia representation
Digital image, video or diagram representing the test result.
Multiple formats are allowed but they should represent equivalent clinical content.
Appended
Subsequent to being final, the report has been modified by adding new content. The existing content is unchanged. This is a sub-category of 'Amended'.
Preliminary
Verified early results are available, but not all results are final. This is a sub-category of 'Partial'.
Test method
Description about the method used to perform the test.
Coding with a terminology is desirable, where possible.
Structured test diagnosis
A structured or complex diagnosis for the laboratory test.
For example: Anatomical pathology diagnoses consisting of several different axes such as morphology, etiology and function.
Laboratory test result
The result, including findings and the laboratory's interpretation, of an investigation performed on specimens collected from an individual or related to that individual.
false
false
true
false
false
true
1
openEHR-EHR-COMPOSITION.report.v1
ErrorTest
Tree
@ internal @
Report ID
Identification information about the report.
Status
The status of the entire report. Note: This is not the status of any of the report components.
Extension
Additional information required to capture local context or to align with other reference models/formalisms.
For example: local information requirements or additional metadata to align with FHIR or CIMI equivalents.
ErrorTest
Document to communicate information to others, commonly in response to a request from another party.
Specimen.collection.collector
Specimen.collection.sourceSite
Specimen.receivedTime
Specimen.collection.quantity
Specimen.type
Specimen.accessionIdentifier
Specimen.identifier
Specimen.collection.method
Specimen.collection.collector
Specimen.note
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