Generated Narrative: StructureDefinition MyHealthEuLabReport Name Flags Card. Type Description & Constraints MyHealthEuLabReport 0..* EHDSLaboratoryReport MyHealth@EU Laboratory report model Elements defined in Ancestors:header, header, presentedForm, header, intendedRecipient[x], body, attachments Instances of this logical model can be the target of a Reference #xD; header #xD; subject O 1..1 MyHealthEuPatient Patient/subject information Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; identifier O 1..* Identifier Unique identifier of the document Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; author[x] O 1..* Author(s) by whom the laboratory result report was authored. Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; authorMyHealthEuHealthProfessional MyHealthEuHealthProfessional #xD; authorMyHealthEuOrganisation MyHealthEuOrganisation #xD; authorMyHealthEuDevice MyHealthEuDevice #xD; date O 1..1 dateTime Date of finalising/issuing the document Obligations Actor SHOULD:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; status O 1..1 CodeableConcept Status of the document Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; language O 0..1 CodeableConcept Language in which the resource is written. Language is expressed by the IETF language tag. Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; documentType O 1..1 CodeableConcept Type of document at hand, e.g. 60591-5 Patient summary document. Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; documentTitle O 1..1 string Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024' Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; version O 0..1 string Business version of the document. The exact algorithm for versioning is decided by the producer/custodian Obligations Actor SHOULD:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; attestation O 0..* Base Document attestation details Obligations Actor MAY:able-to-populate http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; attester[x] O 1..1 Attester who validated the document Obligations Actor SHOULD:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; attesterMyHealthEuHealthProfessional MyHealthEuHealthProfessional #xD; attesterMyHealthEuDevice MyHealthEuDevice #xD; datetime O 1..1 dateTime Date and time of the approval of the document by Attester Obligations Actor SHOULD:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; legalAuthentication O 0..* Base Document legal authentication details Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; legalAuthenticator[x] O 1..1 The person or organisation taking responsibility for the medical content of the document (typically the person who signs it) Obligations Actor SHOULD:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; legalAuthenticatorMyHealthEuHealthProfessional MyHealthEuHealthProfessional #xD; legalAuthenticatorMyHealthEuOrganisation MyHealthEuOrganisation #xD; datetime O 1..1 dateTime Date and time when the document was authorised Obligations Actor SHOULD:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; eventType O 0..* CodeableConcept Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes. Obligations Actor MAY:able-to-populate http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; custodian O 0..1 MyHealthEuOrganisation Organisation that is in charge of maintaining the document/report. Obligations Actor SHOULD:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; presentedForm O 0..* EHDSAttachment A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document Obligations Actor SHOULD:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; intendedRecipient[x] O 0..* Intended recipient Obligations Actor MAY:able-to-populate http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; intendedRecipientMyHealthEuPatient MyHealthEuPatient #xD; intendedRecipientEHDSRelatedPerson EHDSRelatedPerson #xD; intendedRecipientMyHealthEuHealthProfessional MyHealthEuHealthProfessional #xD; intendedRecipientMyHealthEuOrganisation MyHealthEuOrganisation #xD; body #xD; orderInformation O 0..* MyHealthEuLabServiceRequest Order Information (Laboratory Result Report could respond to multiple test orders) Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; supportingInformation #xD; sexForClinicalUse O 0..1 CodeableConcept A Sex Parameter for Clinical Use is a parameter that provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc.. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population Obligations Actor MAY:able-to-populate http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; specimen O 0..* MyHealthEuLabSpecimen Specimen information Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; resultData O 1..1 Base Laboratory report result data Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; commentsInterpretationAndRecommendations O 0..* Narrative Narrative Comments, such as a textual interpretation or advice accompanying the result report, for example. Obligations Actor MAY:able-to-populate http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; laboratoryTestResults O 0..* MyHealthEuLabObservation Observation details (report could consist of multiple observations) Obligations Actor SHALL:handle http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; attachments O 0..* EHDSAttachment Report attachments Obligations Actor MAY:able-to-populate http://hl7.eu/fhir/laboratory/actor-handler-eu-lab #xD; Documentation for this format
MyHealthEu refined model for laboratory result report.
Business identifier for the object, unique within its system. Supporting disambiguation between different contexts (systems/countries).
Author(s) by whom the laboratory result report was authored.
Author(s) by whom the laboratory result report was authored. Multiple authors could be provided.
Author of the laboratory report could be either a health professional who authored the report, laboratory itself or laboratory information system. Author information is the only mandatory element of the laboratory report header. As such, each laboratory shall be able to provide at least the author information.
Date and optionally time of authoring/issuing
Source of information (e.g. patient, patient's proxy). Used in case the patient has authored the information or the author has submitted patient-stated information.
Language in which the resource is written. Language is expressed by the IETF language tag.
Type of document at hand, e.g. 60591-5 Patient summary document.
Human readable document title that can be displayed in search results, etc. This can be documentType's display name, or it can be assembled from multiple elements. Examples: 'Laboratory Result Report', 'Patient Summary of Jane Green 10.12.2024'
Time of service that is being documented
Business version of the document. The exact algorithm for versioning is decided by the producer/custodian
Attester who validated laboratory result report. Multiple attesters could be provided.
Attestation (validation) of the laboratory report content is the usual step before legal authentication. Attestation could be provided by e.g. the laboratory specialist or the laboratory information system based on internal rules of the laboratory.
Date and time of the approval of the document by Attester
The person or organisation taking responsibility for the medical content of the document (typically the person who signs it)
The person or organization taking responsibility for the medical content of the document
Legal authentication of the laboratory report is the usual step after attestation. Legal authentication could be provided by e.g. the head of the laboratory or the laboratory organization itself.
Date and time when the document was authorised
Categorisation of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement between data sharing parties. This meta-data element serves primarily for searching and filtering purposes.
Additional details about where the content was created (e.g. clinical specialty)
Organisation that is in charge of maintaining the document/report.
A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document
Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable
Order Information (Laboratory Result Report could respond to multiple test orders)
An identifier of the laboratory test order. Laboratory Result Report may respond to multiple orders.
The person/organisation "authorised" to place the order. Order placer could be either a health professional, health professional organisation or the patient himself.
An explanation or justification for why this service is being requested in coded form.
Specification of clinical question (goal of the investigation) to be answered by the laboratory investigation.
Additional clinical information about the patient or specimen that may influence the services or their interpretations. This information includes diagnosis, clinical findings and other observations. In laboratory ordering these are typically referred to as 'ask at order entry questions (AOEs).' This includes observations explicitly requested by the producer (filler) to provide context or supporting information needed to complete the order. For example, reporting the amount of inspired oxygen for blood gas measurements.
Clinical findings and other observations.
Condition that may influence the service or result interpretation.
Medication administered before ordering the service.
A Sex Parameter for Clinical Use is a parameter that provides guidance on how a recipient should apply settings or reference ranges that are derived from observable information such as an organ inventory, recent hormone lab tests, genetic testing, menstrual status, obstetric history, etc.. This property is intended for use in clinical decision making, and indicates that treatment or diagnostic tests should consider best practices associated with the relevant reference population
Any other type of relevant supporting information
Specification of requested service or services
Narrative Comments, such as a textual interpretation or advice accompanying the result report, for example.
Observation details (report could consist of multiple observations)