template
    openEHR-EHR-CLUSTER.nehta_specimen.v1

specialise
openEHR-EHR-CLUSTER.specimen.v1

concept
[at0000] -- Specimen

definition /items[at0002] passthrough -- Identification
/items[at0002]/items[at0031] occurrences {0} { -- Provider order identifier
/items[at0002]/items[at0032] occurrences {0} { -- Requester order identifier
/items[at0002]/items[at0003] occurrences {0} { -- Parent specimen identifier
/items[at0046]passthrough -- Processing
/items[at0046]/items[at0015]/name { -- Date and time of collection
DV_TEXT {"Date/time specimen collected"}
}
ELEMENT[at0067] occurrences {0..1} { -- Collection setting value {
DV_TEXT {*}
}
}
ELEMENT[at0034] occurrences {0..1} { -- Date and time of receipt value {
DV_DATE_TIME {*}
}
}
ELEMENT[at0035] occurrences {0..1} { -- Date and time processed value {
DV_DATE_TIME {*}
}
}
}
}
CLUSTER[at0050] occurrences {0..1} { -- Collection and handling items cardinality {0..*; unordered} {
ELEMENT[at0005] occurrences {0..1} { -- Potential Risk / Biohazard value {
DV_TEXT {*}
}
}
ELEMENT[at0029] occurrences {0..1} { -- Specimen type value {
DV_TEXT {*}
}
}
ELEMENT[at0008] occurrences {0..1} { -- Preconditions value {
DV_TEXT {*}
}
}
ELEMENT[at0007] occurrences {0..1} { -- Collection procedure value {
DV_TEXT {*}
}
}
ELEMENT[at0025] occurrences {0..1} { -- Transport medium value {
DV_TEXT {*}
}
}
}
}
CLUSTER[at0019] occurrences {0..1} { -- Physical details items cardinality {0..*; unordered} {
allow_archetype CLUSTER[at0013] occurrences {0..1} { -- Site archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location\.v1|openEHR-EHR-CLUSTER\.localisation\.v1/} archetype_id/value matches {/.*/} } includeexcludeallow_archetype CLUSTER[at0027] occurrences {0..1} { -- Physical properties archetype_id/value matches {/openEHR-EHR-CLUSTER\.physical_properties\.v1/} includeexclude archetype_id/value matches {/.*/} } ELEMENT[at0051] occurrences {0..*} { -- Images value {
DV_MULTIMEDIA {
media_type {
[openEHR::425,
426,
427,
428,
429,
401,
402,
404,
405,
406,
407,
414,
637] } } } } } } CLUSTER[at0049] occurrences {0..1} { -- Additional preparation items cardinality {0..*; unordered} {
allow_archetype CLUSTER[at0068] occurrences {0..*} { -- Specific additional prepartion archetype_id/value matches {/openEHR-EHR-CLUSTER\.specimen_preparation\.v1/} includeexclude archetype_id/value matches {/.*/} } } } CLUSTER[at0038] occurrences {0..1} { -- Quality issues items cardinality {0..*; unordered} {
CLUSTER[at0039] occurrences {0..1} { -- Specimen characteristic issues items cardinality {0..*; unordered} {
ELEMENT[at0042] occurrences {0..*} { -- Issue value {
DV_CODED_TEXT {
defining_code {
[local::at0052, -- Haemolysed at0053, -- Lipaemic at0054, -- Incorrect transport medium at0055] -- Insufficient sample } } } } ELEMENT[at0045] occurrences {0..1} { -- Description value {
DV_TEXT {*}
}
}
}
}
CLUSTER[at0040] occurrences {0..1} { -- Laboratory handling issues items cardinality {0..*; unordered} {
ELEMENT[at0044] occurrences {0..1} { -- Issue value {
DV_CODED_TEXT {
defining_code {
[local::at0056, -- Handling error at0057, -- Age at0058, -- Laboratory accident at0059] -- Technical failure } } } } ELEMENT[at0043] occurrences {0..1} { -- Description value {
DV_TEXT {*}
}
}
}
}
CLUSTER[at0060] occurrences {0..1} { -- Adequacy for testing items cardinality {0..*; unordered} {
ELEMENT[at0041] occurrences {0..1} { -- Adequacy value {
DV_CODED_TEXT {
defining_code {
[local::at0062, -- Satisfactory at0063, -- Unsatisfactory - processed at0064] -- Unsatisfactory - not processed } } } } ELEMENT[at0061] occurrences {0..1} { -- Description value {
DV_TEXT {*}
}
}
}
}
}
}
}
}

ontology term_definitions = <
["en"] = <
items = <
["at0000"] = <
text = <"Specimen">
description = <"To record details of a laboratory specimen">
>
["at0001"] = <
text = <"Specimen identifier">
description = <"Unique identifier of the specimen, normally assigned by the laboratory.">
>
["at0002"] = <
text = <"Identification">
description = <"Sample identifications.">
>
["at0003"] = <
text = <"Parent specimen identifier">
description = <"Unique identifier of the parent specimen, where the specimen is split into sub-samples">
>
["at0005"] = <
text = <"Potential Risk / Biohazard">
description = <"Any risk or biohazard associated with collecting or handling the specimen.">
>
["at0007"] = <
text = <"Collection procedure">
description = <"The method of collection to be used e.g Venepuncture, biopsy. resection">
>
["at0008"] = <
text = <"Preconditions">
description = <"Any conditions to be met before the sample should be taken e.g. fasting, 'full bladder', 'sterile field' or any special instructions on the handling or immediate processing of the sample e.g. centrifuge on receipt.

Can also be used to document any known deviations from collection or handling instructions e.g patient was not fasted."
>
>
["at0013"] = <
text = <"Site ">
description = <"The anatomical site from where the specimen was taken.">
>
["at0015"] = <
text = <"Date and time of collection">
description = <"The date and time that collection has been ordered to take place or has taken place.">
>
["at0019"] = <
text = <"Physical details">
description = <"Specific physical properties of the specimen">
>
["at0025"] = <
text = <"Transport medium">
description = <"Any special preservative or transport medium requirements">
>
["at0027"] = <
text = <"Physical properties">
description = <"Dimensions of sample">
>
["at0029"] = <
text = <"Specimen type">
description = <"The type of specimen to be collected e.g venous blood, prostatic biopsy. ">
>
["at0031"] = <
text = <"Provider order identifier">
description = <"The ID assigned to the Order by the Order Filler, usually by the Laboratory Information System. Equivalent to the DICOM Accession Number, NEHTA Laboratory Request Identifier and HL7 Filler order ID.">
>
["at0032"] = <
text = <"Requester order identifier">
description = <"The ID assigned to the order by the order requester. Equivalent to the HL7 Placer Order ID">
>
["at0034"] = <
text = <"Date and time of receipt">
description = <"The date and time that the sample was received at the laboratory.">
>
["at0035"] = <
text = <"Date and time processed">
description = <"The date and time that the specimen was processed.">
>
["at0038"] = <
text = <"Quality issues">
description = <"Issues of quality with the specimen.">
>
["at0039"] = <
text = <"Specimen characteristic issues">
description = <"Problems with the received specimen. ">
>
["at0040"] = <
text = <"Laboratory handling issues">
description = <"Issues of quality arising during handling and processing within the lab.">
>
["at0041"] = <
text = <"Adequacy">
description = <"Is the specimen adequate for testing?">
>
["at0042"] = <
text = <"Issue">
description = <"Specific issue with a received specimen">
>
["at0043"] = <
text = <"Description">
description = <"A text description of lab handling issues.">
>
["at0044"] = <
text = <"Issue">
description = <"Issue arising with handling or processing of the specimen within the laboratory.">
>
["at0045"] = <
text = <"Description">
description = <"Detailed description of the quality of the received specimen.">
>
["at0046"] = <
text = <"Processing">
description = <"Workflow of specimen handling.">
>
["at0049"] = <
text = <"Additional preparation">
description = <"Details of further preparation of the specimen after receipt at the laboratory.">
>
["at0050"] = <
text = <"Collection and handling">
description = <"Collection and handling requirements.">
>
["at0051"] = <
text = <"Images">
description = <"Any multimedia representations of the specimen e.g digital photgraphs, slide images.">
>
["at0052"] = <
text = <"Haemolysed">
description = <"The specimen was haemolysed">
>
["at0053"] = <
text = <"Lipaemic">
description = <"The specimen was lipaemic">
>
["at0054"] = <
text = <"Incorrect transport medium">
description = <"An incorrect preservative was used when transporting the specimen">
>
["at0055"] = <
text = <"Insufficient sample">
description = <"An insufficient sample was given to undertake measurement">
>
["at0056"] = <
text = <"Handling error">
description = <"An error arose when handling the specimen">
>
["at0057"] = <
text = <"Age">
description = <"The specimen was too old to analyse accurately">
>
["at0058"] = <
text = <"Laboratory accident">
description = <"An accident occurred with the sample in the laboratory">
>
["at0059"] = <
text = <"Technical failure">
description = <"The specimen could not be analysed for technical reasons">
>
["at0060"] = <
text = <"Adequacy for testing">
description = <"An overall evaluation of whether the specimen quality is sufficiently adequate to be processed. ">
>
["at0061"] = <
text = <"Description">
description = <"A detailed description of the evaluation of specimen adequacy for testing purposes.">
>
["at0062"] = <
text = <"Satisfactory">
description = <"The specimen is of sufficient quality to allow reporting">
>
["at0063"] = <
text = <"Unsatisfactory - processed">
description = <"The specimen is unsatisfactory but has been processed">
>
["at0064"] = <
text = <"Unsatisfactory - not processed">
description = <"The specimen is unsatisfactory and has not been processed">
>
["at0067"] = <
description = <"Identification of the setting at which the specimen was collected
from a subject of care. The specimen is often collected by a
healthcare provider, but may be collected directly by the patient or
the patient's carer at home."
>
text = <"Collection setting">
comment = <"This specifies the specimen collection location within the healthcare
environment. It enables the laboratory to ask questions about the
collection of the specimen, if required. The specimen collection
setting may provide additional information relevant to the analysis
of the result data."
>
>
["at0068"] = <
text = <"Specific additional prepartion ">
description = <"The specimen preparation cluster allows detailed recording of a particular preparation step e.g staining or fixation.">
>
["at0070"] = <
text = <"Specimen collector identifier">
description = <"An identifier of the person or agency responsible for collecting the specimen.">
>
>
>
>