Transaction: Laboratory result
General information
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.1
DATE:
2022-07-01
DEFINITION:
The Laboratory result transaction aims to transfer the results of examinations performed by the following medical specialties: laboratory, anatomopathology, genetics, bacteriology, molecular biology and toxicology.
Results from a clinical investigation should be reported through the transaction Contact report.
Results from other technical tests are reported through the transaction Laboratory result.
IMPORTANT:
Please note in there will be an evolution to a laboratory result message specification in HL7 FHIR.
If you have any specific questions about this, please contact us via our portal: https://be-ehealth-standards.atlassian.net/servicedesk/customer/portals
STATUS:
Published
OWNER:
eHealth Platform
STANDARD:
KMEHR
VERSION:
1.1
DATE:
2022-07-01
DEFINITION:
The Laboratory result transaction aims to transfer the results of examinations performed by the following medical specialties: laboratory, anatomopathology, genetics, bacteriology, molecular biology and toxicology.
Results from a clinical investigation should be reported through the transaction Contact report.
Results from other technical tests are reported through the transaction Laboratory result.
IMPORTANT:
Please note in there will be an evolution to a laboratory result message specification in HL7 FHIR.
If you have any specific questions about this, please contact us via our portal: https://be-ehealth-standards.atlassian.net/servicedesk/customer/portals
Guidelines
Generalities
This transaction only requires a level 1 of kmehr normalization. However, further levels may be applied (see structure overview).
Transaction elements
| Element | Purpose |
|---|---|
|
id |
id of the transaction according to the ID-KMEHR convention. |
|
cd |
You must use the value 'labresult' from CD-TRANSACTION. You can always add your own local codes. |
|
date |
This is the date of the reporting of the examination(s). By default, this is also the performing date of the examination. If these two dates differ, the performing date should be defined at the item level. |
|
time |
This is the time of the reporting of the examination(s). |
|
author |
This is the person assuming the responsibility of medical content of the result. |
|
iscomplete |
If this is false, this means that you transfer only part of the information and that the recipient should expect a more complete version later. It is not allowed to use a 'true' value if at least one underlying item has the value 'false' for that element. |
|
isvalidated |
If this is false, this means that the information has not been validated medically. It is not allowed to use a 'true' value if at least one underlying item has the value 'false' for that element. |
Structure overview
You have the choice between:
- text(s): to transfer your result as free text,
- lnk(s): to encapsulate your result as a multimedia object (Word document for example) or to link the result with the requesting transaction,
- heading(s): to organise the results by paragraphs and subparagraphs,
- items(s): to further structure your result.
The structuration by items is strongly recommended.
Headings
We recommend to use values from CD-HEADING-LAB to organise the results by paragraphs and sub paragraphs.
Headings can also be used to group the items belonging to a same specimen when different specimens are reported within a same transaction. In that case, the heading.cd element will refer to the CD-SITE specimen reference table. It is not mandatory to group the items through headings as the specimen can be specified at each item level using the site element.
Items
Any item from CD-ITEM can be used but we recommend more particularily the following ones.
| Item type (cd) | Item purpose | Item structure |
|---|---|---|
| requestnumber | should contain the result number as free text or using KMEHR id; a same transaction can report multiple requests. | content (text | id) |
| requestdatetime | should contain the request date and time | content (date time) |
| specimendatetime | should contain the date and time when the specimen was taken from the patient . If the report refers to multiple specimens, this item should be placed in each related heading. | content (date time) |
| receptiondatetime | should contain the date and time when the specimen was received at the laboratory. If the report refers to multiple specimens, this item should be placed in each related heading. | content (date time) |
| requestor | should identify the prescriber | content hcparty |
| conclusion | could be used to summarise the conclusion of all examinations reported within this transaction. A conclusion could be associated per heading. | content (text | cd) |
| transactionreason | could be used to specify the indication(s) of the examinatio | content text |
|
lab A second cd element should identify precisely the the reported service service using a value from CD-LAB. A local code could be used to specify the method. |
contains the report on each individual laboratory test | content (text | decimal | ...) |
| [author]
to specify the person that assumes the medical responsability of the result if (s)he differs from the transaction author |
||
| [beginmoment]
to specify the date and time when the test has been performed if it differs from the transaction date (and time) of reporting. This can also be used to specify the exact time of dynamic tests. |
||
| [lifecyle]
to specify the performing status using a value from CD-LIFECYCLE. By default, items contained within a laboratory result transaction must be considered as 'reported'. But the following values can be used: 'reported', 'completed' (to inform that the service has been performed but not yet reported), 'planned', 'cancelled'. |
||
| [site]
to specify the specimen, using a value of CD-SITE |
||
| [unit]
to specify the unit, using a value from CD-UNIT. That unit also applies to the reference values (in the elements minref, maxref, refscope). |
||
| [minref] to specify the minimal reference value, generally as decimal; sometimes as free text. |
||
| [maxref] to specify the maximal reference value, generally as decimal; sometimes as free text. |
||
| [refscope]
a value from CD-REFSCOPE and, optionally, refvalue elements for each concept of the scope (age range, sex, ...) |
||
|
[severity] to specify the 'abnormality' status (value of CD-SEVERITY) |
Generalities
This transaction only requires a level 1 of kmehr normalization. However, further levels may be applied (see structure overview).
Transaction elements
| Element | Purpose |
|---|---|
|
id |
id of the transaction according to the ID-KMEHR convention. |
|
cd |
You must use the value 'labresult' from CD-TRANSACTION. You can always add your own local codes. |
|
date |
This is the date of the reporting of the examination(s). By default, this is also the performing date of the examination. If these two dates differ, the performing date should be defined at the item level. |
|
time |
This is the time of the reporting of the examination(s). |
|
author |
This is the person assuming the responsibility of medical content of the result. |
|
iscomplete |
If this is false, this means that you transfer only part of the information and that the recipient should expect a more complete version later. It is not allowed to use a 'true' value if at least one underlying item has the value 'false' for that element. |
|
isvalidated |
If this is false, this means that the information has not been validated medically. It is not allowed to use a 'true' value if at least one underlying item has the value 'false' for that element. |
Structure overview
You have the choice between:
- text(s): to transfer your result as free text,
- lnk(s): to encapsulate your result as a multimedia object (Word document for example) or to link the result with the requesting transaction,
- heading(s): to organise the results by paragraphs and subparagraphs,
- items(s): to further structure your result.
The structuration by items is strongly recommended.
Headings
We recommend to use values from CD-HEADING-LAB to organise the results by paragraphs and sub paragraphs.
Headings can also be used to group the items belonging to a same specimen when different specimens are reported within a same transaction. In that case, the heading.cd element will refer to the CD-SITE specimen reference table. It is not mandatory to group the items through headings as the specimen can be specified at each item level using the site element.
Items
Any item from CD-ITEM can be used but we recommend more particularily the following ones.
| Item type (cd) | Item purpose | Item structure |
|---|---|---|
| requestnumber | should contain the result number as free text or using KMEHR id; a same transaction can report multiple requests. | content (text | id) |
| requestdatetime | should contain the request date and time | content (date time) |
| specimendatetime | should contain the date and time when the specimen was taken from the patient . If the report refers to multiple specimens, this item should be placed in each related heading. | content (date time) |
| receptiondatetime | should contain the date and time when the specimen was received at the laboratory. If the report refers to multiple specimens, this item should be placed in each related heading. | content (date time) |
| requestor | should identify the prescriber | content hcparty |
| conclusion | could be used to summarise the conclusion of all examinations reported within this transaction. A conclusion could be associated per heading. | content (text | cd) |
| transactionreason | could be used to specify the indication(s) of the examinatio | content text |
|
lab A second cd element should identify precisely the the reported service service using a value from CD-LAB. A local code could be used to specify the method. |
contains the report on each individual laboratory test | content (text | decimal | ...) |
| [author]
to specify the person that assumes the medical responsability of the result if (s)he differs from the transaction author |
||
| [beginmoment]
to specify the date and time when the test has been performed if it differs from the transaction date (and time) of reporting. This can also be used to specify the exact time of dynamic tests. |
||
| [lifecyle]
to specify the performing status using a value from CD-LIFECYCLE. By default, items contained within a laboratory result transaction must be considered as 'reported'. But the following values can be used: 'reported', 'completed' (to inform that the service has been performed but not yet reported), 'planned', 'cancelled'. |
||
| [site]
to specify the specimen, using a value of CD-SITE |
||
| [unit]
to specify the unit, using a value from CD-UNIT. That unit also applies to the reference values (in the elements minref, maxref, refscope). |
||
| [minref] to specify the minimal reference value, generally as decimal; sometimes as free text. |
||
| [maxref] to specify the maximal reference value, generally as decimal; sometimes as free text. |
||
| [refscope]
a value from CD-REFSCOPE and, optionally, refvalue elements for each concept of the scope (age range, sex, ...) |
||
|
[severity] to specify the 'abnormality' status (value of CD-SEVERITY) |