LaboratoryTestResult-v4.1(2017EN)

Attention!! This is not the most recent version of this information model. You can find the most recent version ''here''.

General information

Name: nl.zorg.LaboratoryTestResult
Version: 4.1
HCIM Status:Final
Release: 2017
Release status: Published
Release date: 31-12-2017

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Metadata

DCM::CoderList	Kerngroep Registratie aan de Bron
DCM::ContactInformation.Address	*
DCM::ContactInformation.Name	*
DCM::ContactInformation.Telecom	*
DCM::ContentAuthorList	Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::CreationDate	7-6-2012
DCM::DeprecatedDate
DCM::DescriptionLanguage	nl
DCM::EndorsingAuthority.Address
DCM::EndorsingAuthority.Name	PM
DCM::EndorsingAuthority.Telecom
DCM::Id	2.16.840.1.113883.2.4.3.11.60.40.3.13.1
DCM::KeywordList	laboratorium uitslag, lab, laboratorium bepaling
DCM::LifecycleStatus	Final
DCM::ModelerList	Kerngroep Registratie aan de Bron
DCM::Name	nl.zorg.LaboratoriumUitslag
DCM::PublicationDate	31-12-2017
DCM::PublicationStatus	Published
DCM::ReviewerList	Projectgroep Generieke Overdrachtsgegevens & Kerngroep Registratie aan de Bron
DCM::RevisionDate	31-12-2017
DCM::Superseeds	nl.zorg.LaboratoriumUitslag-v4.0
DCM::Version	4.1
HCIM::PublicationLanguage	EN

Revision History

Only available in Dutch

Publicatieversie 1.0 (15-02-2013)

Publicatieversie 1.1 (01-07-2013)

Publicatieversie 1.2 (01-04-2015)

ZIB-238	In de klinische bouwsteen OverdrachtLabUitslag de tagged value DCM::ValueSet LOINC - eLab valueset van concept TestNaam opsplitsen.
ZIB-239	In de klinische bouwsteen OverdrachtLabUitslag de tagged value DCM::ValueSet SNOMED - eLab valueset van concept Testmethode opsplitsen.
ZIB-240	In de klinische bouwsteen OverdrachtLabUitslag kwam de tagged value DCM::ValueSet van concept LaboratoriumTest niet overeen met de naam van de gekoppelde waardenlijst ResultNormalcyStatus Valueset (HL7).
ZIB-241	In de klinische bouwsteen OverdrachtLabUitslag de tagged value DCM::ValueSet LOINC - eLab valueset van concept Onderzoek opsplitsen.
ZIB-242	In de klinische bouwsteen OverdrachtLabuitslag kwam de naam van de gekoppelde waardenlijst van concept ResultaatStatus niet overeen met de tagged value van het concept.
ZIB-243	In de klinische bouwsteen OverdrachtLabuitslag kwam de naam van de gekoppelde waardenlijst van concept ResultaatType niet overeen met de tagged value van het concept.
ZIB-244	Tagged values van concept Onderzoek van OverdrachtLabUitslag aangepast, door tagged value DCM:ValueSet e-lab een codelijst naam te geven incl. in tagged value notes verwijzing naar extern codesystem.
ZIB-245	Tagged values van concept Testmethode van OverdrachtLabUitslag aangepast, door tagged value DCM:ValueSet e-lab een codelijst naam te geven incl. in tagged value notes verwijzing naar extern codesystem.
ZIB-246	Tagged values van concept TestNaam van OverdrachtLabUitslag aangepast, door tagged value DCM:ValueSet e-lab een codelijst naam te geven incl. in tagged value notes verwijzing naar extern codesystem.
ZIB-353	Tagged values DCM::CodeSystem aanpassen naar DCM::ValueSet incl. gekoppelde codelijst.
ZIB-361	Naamgeving concept Opmerking aangepast
ZIB-367	Opschonen ResultaatVlaggenCodelijst
ZIB-370	ResultaatStatusCodelijst en TekstUitslagCodelijst codes aanpassen

Incl. algemene wijzigingsverzoeken:

ZIB-94	Aanpassen tekst van Disclaimer, Terms of Use & Copyrights
ZIB-154	Consequenties opsplitsing Medicatie bouwstenen voor overige bouwstenen.
ZIB-200	Naamgeving SNOMED CT in tagged values klinische bouwstenen gelijk getrokken.
ZIB-201	Naamgeving OID: in tagged value notes van klinische bouwstenen gelijk getrokken.
ZIB-309	EOI aangepast
ZIB-324	Codelijsten Name en Description beginnen met een Hoofdletter
ZIB-326	Tekstuele aanpassingen conform de kwaliteitsreview kerngroep 2015

Publicatieversie 1.2.1 (22-05-2015)

ZIB-392

De ResultaatTypeCodelijst heeft geen "OID: " aanduiding in de onderliggende codelijst.

Publicatieversie 1.2.2 (16-07-2015)

ZIB-420

Vervallen SNOMED CT code in ResultaatTypeCodelijst

Publicatieversie 3.0 (01-05-2016)

ZIB-423	Verkeerd bron-codestelsel gekoppeld aan de 'TestStatusCodelijst'.
ZIB-453	Wijziging naamgeving ZIB's en logo's door andere opzet van beheer

Publicatieversie 4.0 (04-09-2017)

ZIB-479	Monster herkomst ontbreekt
ZIB-549	De Engelse naam van de bouwsteen en het rootconcept zijn niet correct
ZIB-564	Aanpassing/harmonisatie Engelse conceptnamen
ZIB-576	Aanpassen bouwstenen die nog de prefix overdracht hebben, zodat de prefix kan vervallen.
ZIB-481	Ambiguïteit in interpretatie van ResultaatStatus
ZIB-577	Toevoegen SNOMED CT concept in ResultaatTypeCodelijst

Publicatieversie 4.1 (31-12-2017)

ZIB-609	Biopsie niet in AfnameprocedureCodelijst
ZIB-611	cardinaliteit ResultaatType
ZIB-621	Aanpassingen naar aanleiding van overleg met NHG
ZIB-645	Diverse terminologiekoppelingen lijken niet te kloppen
ZIB-646	Aanpassing SNOMED codes

Concept

A laboratory result describes the result of a laboratory analysis.
These are specimen-oriented tests as performed in laboratories such as Clinical Chemistry, Serology, Microbiology, etc.
In addition to the results of tests with a singular result, this concept can also contain the results of more complex tests with multiple results or a ‘panel’.

Purpose

Laboratory tests are done for the purpose of diagnosing and preventing disease and follow-up on the effects of treatment.

Evidence Base

There are two information models for recording laboratory test results: TextResult and LaboratoryTestResult.

In the case of laboratory test results, it is difficult to clearly indicate exactly when to use this information model and when to use the TextResult information model.
In general, laboratory tests resulting in a value (7.1 mmol/L), ordinal number (++ from series to ++++) or a quantitative result (Low) are recorded using this information model. The TextResult information model is better suited for textual results that are more descriptive in nature and which are longer than just a few words. Both types of tests occur in almost all laboratories.
The applicability of the aforementioned information models is not determined by the kind of lab but by the kind of result.

Information Model

Type	Id	Concept						Card.	Definition	DefinitionCode	Reference
	NL-CM:13.1.1	LaboratoryTestResult							Root concept of the LaboratoryTestResult information model. This root concept contains all data elements of the LaboratoryTestResult information model.
	NL-CM:13.1.2		Specimen					0..1	Container of the Specimen concept. This container contains all data elements of the Specimen concept.	123038009 monster
	NL-CM:13.1.15			SpecimenId				0..*	Identification number of the material obtained, as a reference for inquiries to the source organization. In a transmural setting, this number will consist of a specimen number including the identification of the issuing organization, to be unique outside of the borders of an organization.
	NL-CM:13.1.20			SpecimenNumberExtension				0..1	The specimen number extension is used when the collected material is distributed from the original tube or container across multiple tubes. In combination with the specimen Id the extension yield a unique identification of the tube or container
	NL-CM:13.1.21			ContainerType				0..1	Container type describes the envelope in which the material is collected or sent. Examples include blood tubes, transport container, possibly including culture medium.		ContainerTypeCodelist
	NL-CM:13.1.16			SpecimenMaterial				0..1	SpecimenMaterial describes the material obtained. If the LOINC test code also implicitly describes a material, this element may not conflict with the description. If desired, this component can provide a more detailed description of the material: LOINC codes only contain the materials at a main level. This is in line with the agreements made in the IHE/Nictiz program e-Lab. If the test is carried out on derived material (such as plasma), this element will still contain the material drawn (in this case, blood). In this case, the LOINC code will generally refer to plasma.	370133003 Specimen substance	SpecimenMaterialCodelist
	NL-CM:13.1.22			Microorganism				0..1	In particular in microbiological determinations the subject of the test is an isolate of certain microorganism rather then a material. This concept provides the ability to capture information about this microorganism.		MicroorganismCodelist
	NL-CM:13.1.23			CollectedVolume				0..1	Total volume of the collected material. If it is necessary to determine the absolute amount of a particular substance in the collected material, the volume thereof must be given.
	NL-CM:13.1.24			CollectionPeriod				0..1	If the material has not been collected at a single point in time but over a certain period, this period can be captured in this concept. An example is 24 hour urine.
	NL-CM:13.1.17			CollectionDateTime				0..1	Time at which the material was collected.	399445004 specimen collection date
	NL-CM:13.1.25			ReceivedDateTime				0..1	Date and time that the material is handed over at the laboratory or specimen collection center. This is the issue with material that is collected by the patient himself.
	NL-CM:13.1.18			CollectionMethod				0..1	If relevant for the results, the method of obtaining the specimen can be entered as well.	118171006 Specimen procedure	CollectionMethodCodelist
	NL-CM:13.1.26			AnatomicalLocation				0..1	Anatomic location where the material is collected, e.g. elbow	118169006 Specimen source topography	SpecimenAnatomicalLocationCodelist
	NL-CM:13.1.27			Laterality				0..1	Laterality adds information about body side to the anatomic location, e.g. left	272741003 Laterality	LateralityCodelist
	NL-CM:13.1.28			Morphology				0..1	Morphology describes morphological abnormalities of the anatomical location where the material is taken, for example wound, ulcer.	118168003 Specimen source morphology	MorphologyCodelist
	NL-CM:13.1.29			SpecimenSource				0..1	If the material is not collected directly from the patient but comes from a patient-related object, e.g. a cathetertip, this source of material can be recorded here.	118170007 Specimen source identity
	NL-CM:13.1.19			Comment				0..1	Comments on administering the test, such as drawing material after a (glucose) stimulus or taking medicine.	48767-8 Annotation comment
	NL-CM:13.1.3		LaboratoryTest					0..*	Container of the LaboratoryTest concept. This container contains all data elements of the LaboratoryTest concept.
	NL-CM:13.1.8			TestCode				1	The name and code of the executed test.		TestNameCodelist
	NL-CM:13.1.9			TestMethod				0..1	The test method used to obtain the result.	246501002 Technique (attribute)	TestMethodCodelist
	NL-CM:13.1.13			TestDateTime				0..1	The date and if possible the time at which the test was carried out.
	NL-CM:13.1.10			TestResult				0..1	The test result. Depending on the type of test, the result will consist of a value with a unit or a coded value (ordinal or nominal).
	NL-CM:13.1.31			TestResultStatus				0..1	The status of the test result of this test. If the laboratory test is an panel/cluster, the overall status is given in the status of the panel/cluster.		TestResultStatusCodelist
	NL-CM:13.1.11			ReferenceRangeUpperLimit				0..1	The upper reference limit for the patient of the value measured in the test.
	NL-CM:13.1.12			ReferenceRangeLowerLimit				0..1	The lower reference limit for the patient of the value measured with the test.
	NL-CM:13.1.30			InterpretationMethod				0..1	The method used to determine interpretation flags. An example of this is EUCAST, for determining clinical breakpoints in microbiological susceptibility tests		InterpretationMethodCodelist
	NL-CM:13.1.14			ResultFlags				0..*	Attention codes indicating whether the result is above or below certain reference values or interpreting the result otherwise.(Resistent)	363713009 Has interpretation	ResultFlagsCodelist
	NL-CM:13.1.32			ResultInterpretation				0..1	Comment of the laboratory specialist regarding the interpretation of the results	441742003 Evaluation finding
	NL-CM:13.1.4		PanelOrBattery					0..1	For laboratory tests comprising multiple subtests and often requested together as a whole, this concept contains the name of the compound request (often indicated as a ‘panel’, ‘battery’ or ‘cluster’). Examples include: blood gases and EBV serology.		PanelOrBatteryCodelist
	NL-CM:13.1.6		ResultStatus					0..1	The status of the laboratory test result .If the laboratory test is an panel/cluster, this status reflects the status of the whole panel/cluster. If the status item per subtest is used too, this status must be in accordance with these status values.		ResultStatusCodelist
	NL-CM:13.1.5		Comment					0..1	Comments, such as a textual interpretation or advice accompanying the result, for example.	48767-8 Annotation comment
	NL-CM:13.1.7		ResultType					0..1	The type of result defines the laboratory specialty under which the test is categorized.		ResultTypeCodelist
	NL-CM:13.1.33		RelatedResult::LaboratoryTestResult					0..*	Reference to related tests, e.g. paired tests or sequential tests like gram staining and microbiological cultures		LaboratoryTestResult
	NL-CM:13.1.34		Requester::HealthProfessional					0..1	The healthcare provider and/or organization where or by whom the LaboratoryTestResult was requested.		HealthProfessional

Columns Concept and DefinitionCode: hover over the values for more information
For explanation of the symbols, please see the legend page

Example Instances

Only available in Dutch

LaboratoriumUitslag
Resultaat Type	Resultaat Status	Monster		LaboratoriumTest
		Monster materiaal	Afname DatumTijd	TestCode	Test DatumTijd	TestUitslag	Referentie Ondergrens	Referentie Bovengrens	Interpretatie Vlaggen
Klinische chemie	Definitief	Bloed	12-06-2012 09:00	Natrium	12-06-2012 13:15	138 mmol/l	136 mmol/l	146 mmol/l

LaboratoriumUitslag
Resultaat Type	Resultaat Status	Monster		LaboratoriumTest
		Monster materiaal	Afname DatumTijd	TestCode	Test DatumTijd	TestUitslag	Referentie Ondergrens	Referentie Bovengrens	Interpretatie Vlaggen
Klinische chemie	Definitief	Bloed	23-05-2012 08:08	Chloride	23-05-2012 12:00	109 mmol/l	99 mmol/l	108 mmol/l	Boven referentie- waarde

LaboratoriumUitslag
Resultaat Type	Resultaat Status	Monster		LaboratoriumTest
		Monster materiaal	Afname DatumTijd	TestCode	Test DatumTijd	TestUitslag	Referentie Ondergrens	Referentie Bovengrens	Interpretatie Vlaggen
Virologie	Definitief	Bloed	16-01-2012 08:00	Hepatitis A IgM	16-01-2012 10:12	Negatief

References

1. Nederlandse Vereniging voor Medische Microbiologie (2010) ELab en EvT. [Online] Beschikbaar op: http://www.nvmm.nl/ict/vereniging/werkgroepen_commissies/elab-en-evt [Geraadpleegd: 23 juli 2014].

Valuesets

CollectionMethodCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.2

Binding:

Conceptname	Codesystem name	Codesystem OID
SNOMED CT: <71388002|verrichting (verrichting)|	SNOMED CT	2.16.840.1.113883.6.96

ContainerTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.9

Binding:

Conceptname	Codesystem name	Codesystem OID
SNOMED CT: <434711009|Specimen container (physical object)|	SNOMED CT	2.16.840.1.113883.6.96

InterpretationMethodCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.14

Binding:

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
EUCAST	tbd	SNOMED CT	2.16.840.1.113883.6.96	EUCAST

LateralityCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.12

Binding:

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Left	7771000	SNOMED CT	2.16.840.1.113883.6.96	Links
Right	24028007	SNOMED CT	2.16.840.1.113883.6.96	Rechts
Right and left	51440002	SNOMED CT	2.16.840.1.113883.6.96	Rechts en links

MicroorganismCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.10

Binding:

Conceptname	Codesystem name	Codesystem OID
SNOMED CT: ^2581000146104|simpele referentieset voor micro-organismen (foundation metadata concept)|	SNOMED CT	2.16.840.1.113883.6.96

MorphologyCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.13

Binding:

Conceptname	Codesystem name	Codesystem OID
SNOMED CT: <49755003|Morphologically abnormal structure|	SNOMED CT	2.16.840.1.113883.6.96

PanelOrBatteryCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.5

Binding:

Conceptname	Codesystem name	Codesystem OID
Alle waarden	LOINC	2.16.840.1.113883.6.1

ResultFlagsCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.7

Binding:

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Above reference range	281302008	SNOMED CT	2.16.840.1.113883.6.96	Boven referentiewaarde
Below reference range	281300000	SNOMED CT	2.16.840.1.113883.6.96	Onder referentiewaarde
Intermediate	11896004	SNOMED CT	2.16.840.1.113883.6.96	Intermediair
Resistant	30714006	SNOMED CT	2.16.840.1.113883.6.96	Resistent
Susceptible	131196009	SNOMED CT	2.16.840.1.113883.6.96	Sensitief

ResultStatusCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.8

Binding:

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Pending	pending	ResultaatStatus	2.16.840.1.113883.2.4.3.11.60.40.4.16.1	Uitslag volgt
Preliminary	preliminary	ResultaatStatus	2.16.840.1.113883.2.4.3.11.60.40.4.16.1	Voorlopig
Final	final	ResultaatStatus	2.16.840.1.113883.2.4.3.11.60.40.4.16.1	Definitief
Appended	appended	ResultaatStatus	2.16.840.1.113883.2.4.3.11.60.40.4.16.1	Aanvullend
Corrected	corrected	ResultaatStatus	2.16.840.1.113883.2.4.3.11.60.40.4.16.1	Gecorrigeerd

ResultTypeCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.1

Binding:

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Hematology	252275004	SNOMED CT	2.16.840.1.113883.6.96	Hematologie
Chemistry	275711006	SNOMED CT	2.16.840.1.113883.6.96	Klinische chemie
Serology	68793005	SNOMED CT	2.16.840.1.113883.6.96	Serologie/ immunologie
Virology	395124008	SNOMED CT	2.16.840.1.113883.6.96	Virologie
Toxicology	314076009	SNOMED CT	2.16.840.1.113883.6.96	Toxicologie
Microbiology	19851009	SNOMED CT	2.16.840.1.113883.6.96	Microbiologie
Molecular genetics	405825005	SNOMED CT	2.16.840.1.113883.6.96	Moleculaire genetica

SpecimenAnatomicalLocationCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.11

Binding:

Conceptname	Codesystem name	Codesystem OID
SNOMED CT: <442083009|Anatomical or acquired body structure|	SNOMED CT	2.16.840.1.113883.6.96

SpecimenMaterialCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.6

Binding:

Conceptname	Codesystem name	Codesystem OID
SNOMED CT: <105590001|substantie|	SNOMED CT	2.16.840.1.113883.6.96

TestMethodCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.4

Binding:

Conceptname	Codesystem name	Codesystem OID
SNOMED CT: <272394005|Technique (qualifier value)|	SNOMED CT	2.16.840.1.113883.6.96

TestNameCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.3

Binding:

Conceptname	Codesystem name	Codesystem OID
Alle waarden	LOINC	2.16.840.1.113883.6.1

TestResultStatusCodelist

Valueset OID: 2.16.840.1.113883.2.4.3.11.60.40.2.13.1.15

Binding:

Conceptname	Conceptcode	Codesystem name	Codesystem OID	Description
Pending	pending	ResultaatStatus	2.16.840.1.113883.2.4.3.11.60.40.4.16.1	Uitslag volgt
Preliminary	preliminary	ResultaatStatus	2.16.840.1.113883.2.4.3.11.60.40.4.16.1	Voorlopig
Final	final	ResultaatStatus	2.16.840.1.113883.2.4.3.11.60.40.4.16.1	Definitief
Appended	appended	ResultaatStatus	2.16.840.1.113883.2.4.3.11.60.40.4.16.1	Aanvullend
Corrected	corrected	ResultaatStatus	2.16.840.1.113883.2.4.3.11.60.40.4.16.1	Gecorrigeerd

This information model in other releases

• Release 2015, (Version 1.2.2)
• Release 2016, (Version 3.0)
• Prerelease 2018-2, (Version 4.3)
• Prerelease 2019-2, (Version 4.5)
• Release 2020, (Version 4.6)
• Prerelease 2021-2, (Version 5.0)
• Prerelease 2022-1, (Version 5.1)
• Prerelease 2023-1, (Version 6.0)
• Prerelease 2024-1, (Version 7.0)

Information model references

This information model refers to

• HealthProfessional-v3.2
• LaboratoryTestResult-v4.1

This information model is used in

• LaboratoryTestResult-v4.1

Technical specifications in HL7v3 CDA and HL7 FHIR

To exchange information based on health and care information models, additional, more technical specifications are required.
Not every environment can handle the same technical specifications. For this reason, there are several types of technical specifications:

• HL7® version 3 CDA compatible specifications, available through the Nictiz ART-DECOR® environment
• HL7® FHIR® compatible specifications, available through the Nictiz environment on the Simplifier FHIR

Downloads

This information model is also available as pdf file or as spreadsheet

About this information

The information in this wikipage is based on Release 2017
Conditions for use are located on the mainpage
This page is generated on 21/12/2018 14:10:07 with ZibExtraction v. 3.0.6929.24609

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