{ "description": "A LaboratoryTestResult as defined by the Dutch Health and Care Information models (Dutch: Zorginformatiebouwsteen or ZIB) version 4.1, release 2017.", "_filename": "zib-LaboratoryTestResult-Observation.json", "package_name": "nictiz.fhir.nl.stu3.zib2017", "date": null, "derivation": "constraint", "publisher": "Nictiz", "fhirVersion": "3.0.1", "name": "Zib LaboratoryTestResult Observation", "mapping": [ { "uri": "https://zibs.nl/wiki/LaboratoryTestResultForTransfer-v1.2.2(2015EN)", "name": "HCIM LaboratoryTestResultForTransfer-v1.2.2(2015EN)", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "uri": "https://zibs.nl/wiki/LaboratoryTestResultForTransfer-v3.0(2016EN)", "name": "HCIM LaboratoryTestResultForTransfer-v3.0(2016EN)", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "uri": "https://zibs.nl/wiki/LaboratoryTestResult-v4.1(2017EN)", "name": "HCIM LaboratoryTestResult-v4.1(2017EN)", "identity": "hcim-laboratorytestresult-v4.1-2017EN" }, { "uri": "https://zibs.nl/wiki/BasicElements-v1.0(2017EN)", "name": "HCIM BasicElements-v1.0(2017EN)", "identity": "hcim-basicelements-v1.0-2017EN" } ], "abstract": false, "copyright": "CC0", "type": "Observation", "experimental": null, "resourceType": "StructureDefinition", "title": "HCIM LaboratoryTestResult Observation", "package_version": "1.3.2", "status": "active", "id": "b6d8f44c-71e6-4e86-ba1d-383daf24087a", "kind": "resource", "url": "http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Observation", "version": "2.1.3", "differential": { "element": [ { "id": "Observation", "path": "Observation", "alias": [ "LaboratoriumUitslag" ], "short": "LaboratoryTestResult", "mapping": [ { "map": "NL-CM:13.1.3", "comment": "LaboratoryTest", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.3", "comment": "LaboratoryTest", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.3", "comment": "LaboratoryTest", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "Measurements and simple assertions made about a patient, device or other subject. These may be a simple or a complex observations. Simple Observations could consist of just a code and a value, whereas complex observations like panels and batteries could have related Observations and or components.\r\nThe HCIM LaboratoryResult also supports simple and more complex situations. For a simple result there will be a single LaboratoryTestResult.LaboratoryTest.TestName in Observation.code and no LaboratoryTestresult.Test. For a more complex situation there will be a LaboratoryTestResult.Test and any number of related LaboratoryTestResult.LaboratoryTest, e.g. parts of a panel or battery. Each related LaboratoryTest shall be conveyed in Observation.related or Observation.component. The deciding factor in choosing between related or component is: does the observation have use as independent observation (Observation.related) or is the observation only relevant in the context of its parent (Observation.component).\r\nNote that (textual) reports on individual (panels of) observations, like conclusions, go into a different resource DiagnosticReport. The DiagnosticReport then contains the references to the Observation resources it concerns." }, { "id": "Observation.identifier", "path": "Observation.identifier", "alias": [ "Identificatie" ], "short": "Identifier", "mapping": [ { "map": "NL-CM:0.0.6", "comment": "IdentificationNumber", "identity": "hcim-basicelements-v1.0-2017EN" } ] }, { "id": "Observation.basedOn", "path": "Observation.basedOn", "alias": [ "Aanvrager" ], "short": "Fulfills plan, proposal or order including requester information.", "comment": "Requester information should be captured and exchanged in the resource ProcedureRequest referenced by basedOn. Requester is the healthcare provider and/or organization where or by whom the LaboratoryTestResult was requested. There are a few required elements in ProcedureRequest\r\n - ProcedureRequest.status (use fixed value \"active\", unless you know what the actual value is)\r\n - ProcedureRequest.intent (use fixed value \"order\", unless you know what the actual value is)\r\n - ProcedureRequest.code (use extension http://hl7.org/fhir/STU3/extension-iso21090-nullflavor.html met valueCode UNK, unless you know what the actual value is)\r\n - ProcedureRequest.subject (equal to Observation.subject)\r\n - ProcedureRequest.requester.agent (contains the requesting HealthProfessional)", "mapping": [ { "map": "NL-CM:13.1.34", "comment": "Contains Requester::HealthProfessional", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ] }, { "id": "Observation.status", "path": "Observation.status", "alias": [ "TestUitslagStatus" ], "short": "TestUitslagStatus", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-display-hint", "valueString": "default: final" } ], "definition": "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." }, { "id": "Observation.status.extension", "path": "Observation.status.extension", "slicing": { "rules": "open", "discriminator": [ { "path": "url", "type": "value" } ] } }, { "path": "Observation.status.extension", "definition": "Provides the specific HCIM code for TestResultStatus or ResultStatus.\r\n\r\nThe 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.", "short": "TestResultStatus", "mapping": [ { "map": "NL-CM:13.1.31", "comment": "TestResultStatus", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "type": [ { "code": "Extension", "profile": "http://nictiz.nl/fhir/StructureDefinition/code-specification" } ], "sliceName": "TestResultStatus", "alias": [ "TestUitslagStatus" ], "max": "1", "id": "Observation.status.extension:TestResultStatus" }, { "id": "Observation.status.extension:TestResultStatus.valueCodeableConcept:valueCodeableConcept", "path": "Observation.status.extension.valueCodeableConcept", "binding": { "strength": "extensible", "description": "TestResultStatusCodelist", "valueSetReference": { "display": "TestResultStatusCodelijst", "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.1.8--20171231000000" } }, "sliceName": "valueCodeableConcept" }, { "id": "Observation.category", "min": 1, "path": "Observation.category", "slicing": { "rules": "open", "discriminator": [ { "path": "coding.code", "type": "value" }, { "path": "coding.system", "type": "value" } ] } }, { "id": "Observation.category:LaboratoryTestResultCode", "max": "1", "min": 1, "path": "Observation.category", "short": "LaboratoryTestResultCode", "sliceName": "LaboratoryTestResultCode" }, { "id": "Observation.category:LaboratoryTestResultCode.coding.system", "path": "Observation.category.coding.system", "fixedUri": "http://snomed.info/sct" }, { "id": "Observation.category:LaboratoryTestResultCode.coding.code", "path": "Observation.category.coding.code", "fixedCode": "49581000146104" }, { "id": "Observation.category:LaboratoryTestResultCode.coding.display", "path": "Observation.category.coding.display", "short": "Laboratory test finding (finding)", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ] }, { "path": "Observation.category", "definition": "The type of result defines the laboratory specialty under which the test is categorized.", "short": "ResultType", "mapping": [ { "map": "NL-CM:13.1.7", "comment": "ResultType", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.7", "comment": "ResultType", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.7", "comment": "ResultType", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "sliceName": "ResultType", "binding": { "strength": "extensible", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ObservationCategory" } ], "description": "ResultaatTypeCodelijst", "valueSetReference": { "display": "ResultaatTypeCodelijst", "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.1.1--20171231000000" } }, "alias": [ "ResultaatType" ], "max": "1", "id": "Observation.category:ResultType" }, { "id": "Observation.code", "path": "Observation.code", "alias": [ "TestCode", "Onderzoek" ], "short": "TestCode or PanelOrBattery", "binding": { "strength": "extensible", "description": "LOINC (2.16.840.1.113883.6.1): All values", "valueSetReference": { "display": "OnderzoekCodelijst", "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.1.5--20171231000000" } }, "comment": "This can either be the ZIB concept Test (NL-CM:13.1.4) or TestName (NL-CM:13.1.8) depending on the use of DiagnosticReport resource. This element shall be mapped to TestName if DiagnosticReport is used and .component.code is not used. If component.code is used, the ZIB concept Test shall be mapped to this element.", "mapping": [ { "map": "NL-CM:13.1.4", "comment": "Test", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.4", "comment": "Test", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.4", "comment": "PanelOrBattery", "identity": "hcim-laboratorytestresult-v4.1-2017EN" }, { "map": "NL-CM:13.1.8", "comment": "TestName", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.8", "comment": "TestName", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.8", "comment": "TestCode", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "The name and code of the executed test or 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." }, { "id": "Observation.subject", "path": "Observation.subject", "alias": [ "Patiënt" ], "short": "Patient" }, { "id": "Observation.context", "path": "Observation.context", "short": "Encounter during which this observation is made", "definition": "The encounter during which this journal entry was made." }, { "id": "Observation.effective[x]", "path": "Observation.effective[x]", "alias": [ "TestDatumTijd" ], "short": "TestDateTime", "mapping": [ { "map": "NL-CM:13.1.13", "comment": "TestDateTime", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.13", "comment": "TestDateTime", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.13", "comment": "TestDateTime", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "The date and if possible the time at which the test was carried out." }, { "id": "Observation.value[x]", "path": "Observation.value[x]", "alias": [ "TestUitslag" ], "short": "TestResult", "mapping": [ { "map": "NL-CM:13.1.10", "comment": "TestResult", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.10", "comment": "TestResult", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.10", "comment": "TestResult", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "The test result. Depending on the type of test, the result will consist of a value with a unit or a coded value (ordinal or nominal)." }, { "id": "Observation.interpretation", "path": "Observation.interpretation", "alias": [ "InterpretatieVlaggen" ], "short": "ResultFlags", "binding": { "strength": "extensible", "valueSetReference": { "display": "InterpretatieVlaggenCodelijst", "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.1.7--20171231000000" } }, "comment": "A ConceptMap (https://simplifier.net/resolve?canonical=http://nictiz.nl/fhir/ConceptMap/InterpretatieVlaggenCodelijst-to-observation-interpretation) is available that explains the relationship between the FHIR observation-interpretation value set and the HCIM ResultFlagsCodelist.", "mapping": [ { "map": "NL-CM:13.1.14", "comment": "ResultFlags", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.14", "comment": "ResultFlags", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.14", "comment": "ResultFlags - see ConceptMap 'HCIM InterpretatieVlaggenCodelijst to Observation Interpretation Codes'", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "Attention codes indicating whether the result is above or below certain reference values or interpreting the result otherwise. (Resistent)" }, { "id": "Observation.comment", "path": "Observation.comment", "alias": [ "Toelichting", "UitslagInterpretatie" ], "short": "Comment or ResultInterpretation", "mapping": [ { "map": "NL-CM:13.1.5", "comment": "Explanation", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.5", "comment": "Explanation", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.5", "comment": "Comment", "identity": "hcim-laboratorytestresult-v4.1-2017EN" }, { "map": "NL-CM:13.1.32", "comment": "ResultInterpretation", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "Comments, such as a textual interpretation or advice accompanying the result, for example or a comment of the laboratory specialist regarding the interpretation of the results." }, { "id": "Observation.method", "path": "Observation.method", "alias": [ "Testmethode" ], "short": "TestMethod", "binding": { "strength": "extensible", "description": "SNOMED CT (2.16.840.1.113883.6.96): All values", "valueSetReference": { "display": "TestmethodeCodelijst", "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.1.4--20171231000000" } }, "mapping": [ { "map": "NL-CM:13.1.9", "comment": "TestMethod", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.9", "comment": "TestMethod", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.9", "comment": "TestMethod", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "The test method used to obtain the result." }, { "id": "Observation.specimen", "path": "Observation.specimen", "type": [ { "code": "Reference", "targetProfile": "http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Specimen" }, { "code": "Reference", "targetProfile": "http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Specimen-Isolate" } ], "alias": [ "Monster" ], "short": "Specimen", "mapping": [ { "map": "NL-CM:13.1.2", "comment": "Specimen", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.2", "comment": "Specimen", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.2", "comment": "Specimen", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ] }, { "id": "Observation.device", "path": "Observation.device", "type": [ { "code": "Reference", "targetProfile": "http://nictiz.nl/fhir/StructureDefinition/zib-MedicalDeviceProduct" } ] }, { "id": "Observation.referenceRange", "path": "Observation.referenceRange", "alias": [ "Referentie" ], "short": "Reference" }, { "id": "Observation.referenceRange.low", "path": "Observation.referenceRange.low", "alias": [ "ReferentieOndergrens" ], "short": "ReferenceRangeLowerLimit", "mapping": [ { "map": "NL-CM:13.1.12", "comment": "LowerReferenceLimit", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.12", "comment": "LowerReferenceLimit", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.12", "comment": "ReferenceRangeLowerLimit", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "The lower reference limit for the patient of the value measured with the test." }, { "id": "Observation.referenceRange.high", "path": "Observation.referenceRange.high", "alias": [ "ReferentieBovengrens" ], "short": "ReferenceRangeUpperLimit", "mapping": [ { "map": "NL-CM:13.1.11", "comment": "UpperReferenceLimit", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.11", "comment": "UpperReferenceLimit", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.11", "comment": "ReferenceRangeUpperLimit", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "The upper reference limit for the patient of the value measured in the test." }, { "id": "Observation.related", "path": "Observation.related", "alias": [ "GerelateerdeUitslag" ], "short": "RelatedResults", "mapping": [ { "map": "NL-CM:13.1.33", "comment": "RelatedResults", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "Reference to related tests, e.g. paired tests or sequential tests like gram staining and microbiological cultures.", "requirements": "Normally, an observation will have either a value or a set of related observations. A few observations (e.g. Apgar score) may have both a value and a set of related observations or sometimes QuestionnaireResponse from which the measure is derived." }, { "id": "Observation.related.type", "min": 1, "path": "Observation.related.type", "fixedCode": "has-member" }, { "id": "Observation.related.target", "path": "Observation.related.target", "type": [ { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/QuestionnaireResponse" }, { "code": "Reference", "targetProfile": "http://hl7.org/fhir/StructureDefinition/Sequence" }, { "code": "Reference", "targetProfile": "http://nictiz.nl/fhir/StructureDefinition/zib-LaboratoryTestResult-Observation" } ], "mapping": [ { "map": "NL-CM:13.1.1", "comment": "LaboratoryTestResult", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ] }, { "id": "Observation.component", "path": "Observation.component", "alias": [ "LaboratoriumTest" ], "short": "LaboratoryTest", "mapping": [ { "map": "NL-CM:13.1.3", "comment": "LaboratoryTest", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.3", "comment": "LaboratoryTest", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.3", "comment": "LaboratoryTest", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "Container of the LaboratoryTest concept. This container contains all data elements of the LaboratoryTest concept." }, { "id": "Observation.component.code", "path": "Observation.component.code", "alias": [ "TestCode" ], "short": "TestCode", "binding": { "strength": "extensible", "description": "LOINC (2.16.840.1.113883.6.1): All values", "valueSetReference": { "display": "TestNaamCodelijst", "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.1.3--20171231000000" } }, "mapping": [ { "map": "NL-CM:13.1.8", "comment": "TestName", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.8", "comment": "TestName", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.8", "comment": "TestCode", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "The TestCode is the name of the executed test." }, { "id": "Observation.component.value[x]", "path": "Observation.component.value[x]", "alias": [ "TestUitslag" ], "short": "TestResult", "mapping": [ { "map": "NL-CM:13.1.10", "comment": "TestResult", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.10", "comment": "TestResult", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.10", "comment": "TestResult", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "The test result. Depending on the type of test, the result will consist of a value with a unit or a coded value (ordinal or nominal)." }, { "id": "Observation.component.interpretation", "path": "Observation.component.interpretation", "alias": [ "InterpretatieVlaggen" ], "short": "ResultFlags", "binding": { "strength": "extensible", "description": "InterpretatieVlaggenCodelijst", "valueSetReference": { "display": "InterpretatieVlaggenCodelijst", "reference": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.13.1.7--20171231000000" } }, "comment": "A ConceptMap (https://simplifier.net/resolve?canonical=http://nictiz.nl/fhir/ConceptMap/InterpretatieVlaggenCodelijst-to-observation-interpretation) is available that maps ResultFlagsCodelist to the observation-interpretation valueset.", "mapping": [ { "map": "NL-CM:13.1.14", "comment": "ResultFlags", "identity": "hcim-laboratorytestresultfortransfer-v1.2.2-2015EN" }, { "map": "NL-CM:13.1.14", "comment": "ResultFlags", "identity": "hcim-laboratorytestresultfortransfer-v3.0-2016EN" }, { "map": "NL-CM:13.1.14", "comment": "ResultFlags", "identity": "hcim-laboratorytestresult-v4.1-2017EN" } ], "definition": "Attention codes indicating whether the result is above or below certain reference values or interpreting the result otherwise. (Resistent)" } ] }, "contact": [ { "name": "Nictiz", "telecom": [ { "use": "work", "value": "info@nictiz.nl", "system": "email" } ] } ], "baseDefinition": "http://fhir.nl/fhir/StructureDefinition/nl-core-observation" }