ARCHETYPE Histopathology test (openEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0)

ARCHETYPE IDopenEHR-EHR-OBSERVATION.laboratory_test-histopathology.v0
ConceptHistopathology test
DescriptionThe findings and interpretation of a histopathology test performed on patient-related specimens.
UseUse to record any histopathology test result, including intra-operative, microscopic, macroscopic examinations of tissue. Detailed structured findings are captured within child cluster archetypes. Ancillary laboratory tests may also be captured via the Ancillary Laboratory Test Findings slot. Will normally be reported back to the requesting clinician as one component within the context of an overall COMPOSITION-based report.
MisuseNot to be used for reporting on non-histopathology test results e.g. biochemistry or haematology tests. Not to be used to represent an entire cumulative report. This laboratory test result archetype represents only one of the result sets that is usually viewed as a vertical in a cumulative test report. A cumulative report is a view that is constructed from the results represented by multiple OBSERVATION archetypes. Not to be used to record an Autopsy report, although tests on some specimens that are taken at autopsy may be represented using this archetype.
PurposeTo record the findings and interpretation of histopathology (anatomic pathology) tests performed on tissues and body fluids.
ReferencesBased on NEHTA 'Pathology Test' archetype. Available from: http://dcm.nehta.org.au/ckm/OKM.html#showarchetype_1013.1.839_8

Pathology (Data Specifications) Version 1.0 [Internet]. Sydney, Australia: National E-Health Transition Authority; 2007 May 29 [cited 2011 Jul 11]; Available at http://www.nehta.gov.au/component/docman/doc_download/962-pathology-v10.

Laboratory Technical Framework, Volume 3: Content, Revision 3.0 [Internet]. USA: IHE International; 2011 May 19; [cited 2011 Jul 11]. Available from: http://www.ihe.net/Technical_Framework/index.cfm#laboratory

Hl7 FHIR Diagnostic Report resource: HL7 FHIR; Available from http://www.hl7.org/implement/standards/fhir/diagnosticreport.html
AuthorsAuthor name: Ian McNicoll
Organisation: freshEHR Clinical Informatics
Email: ian@freshehr.com
Date originally authored: 2014-10-15
Other Details LanguageAuthor name: Ian McNicoll
Organisation: freshEHR Clinical Informatics
Email: ian@freshehr.com
Date originally authored: 2014-10-15
OtherDetails Language Independent{licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=Based on NEHTA 'Pathology Test' archetype. Available from: http://dcm.nehta.org.au/ckm/OKM.html#showarchetype_1013.1.839_8 Pathology (Data Specifications) Version 1.0 [Internet]. Sydney, Australia: National E-Health Transition Authority; 2007 May 29 [cited 2011 Jul 11]; Available at http://www.nehta.gov.au/component/docman/doc_download/962-pathology-v10. Laboratory Technical Framework, Volume 3: Content, Revision 3.0 [Internet]. USA: IHE International; 2011 May 19; [cited 2011 Jul 11]. Available from: http://www.ihe.net/Technical_Framework/index.cfm#laboratory Hl7 FHIR Diagnostic Report resource: HL7 FHIR; Available from http://www.hl7.org/implement/standards/fhir/diagnosticreport.html, original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=5D4C5CFDABE14897E91B4F3FD7B774A3, build_uid=207ba8b8-f11a-4ae7-a927-17f656645e6e, revision=0.0.1-alpha}
Keywordslab, pathology, biochemistry, haematology, microbiology, immunology, laboratory, anatomical, chemical, clinical, immunopathology, cytology, histopathology, test, biopsy, specimen, forensic, genetic
Lifecyclein_development
UID69dfbb94-5540-47c4-b9eb-be25849b1890
Language useden
Citeable Identifier1051.32.348
Revision Number0.0.1-alpha
AllArchetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=The findings and interpretation of a histopathology test performed on patient-related specimens., archetypeConceptComment=null, otherContributors=Koray Atalag, University of Auckland, New Zealand
Sharmila Biswas, Dr Sharmila Biswas GP, Australia
Doug Chesher, PaLMS, Australia
Stephen Chu, NEHTA, Australia (Editor)
Matthew Cordell, NEHTA, Australia
Andre de Wolf, NeHTA, Australia
Gail Easterbrook, Flinders Medical Centre, Australia
David Evans, Queensland Health, Australia
Shahla Foozonkhah, Ocean Informatics, Australia
Heath Frankel, Ocean Informatics, Australia
Grahame Grieve, Health Intersections Pyty Ltd, Australia (Editor)
Sam Heard, Ocean Informatics, Australia
Mary Kelaher, NEHTA, Australia
Michael Legg, Michael Legg & associates, Australia
Heather Leslie, Ocean Informatics, Australia (Editor)
Mike Martyn, The Hobart Anaesthetic Group, Australia
Andrew McIntyre, Medical-Objects, Australia
David McKillop, NEHTA, Australia
Ian McNicoll, Ocean Informatics UK, United Kingdom
Chris Mitchell, RACGP, Australia
Stewart Morrison, NEHTA, Australia
Michael Osborne, Mater Health Services, Australia
Kyle Shore, Charm Health, Australia
Michael Thompson, Queensland Health, Australia
Gordon Tomes, Australian Institute of Health and Welfare, Australia
Richard Townley-O'Neill, NEHTA, Australia
David Rowed, VAMC Clinic, Australia (Editor)
Mona Saleh (Translator), originalLanguage=en, translators=
  • Arabic (Syria): Mona Saleh

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    • Registered [The existence of the test is registered in the Laboratory Information System, but there is nothing yet available.]
    • Partial [This is a partial (e.g. initial, interim or preliminary) Test Result: data in the Test Result may be incomplete or unverified.]
    • Final [The Test result is complete and verified by an authorised person.]
    • Corrected [The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist.]
    • Amended [The result has been modified subsequent to being Final, and is complete and verified by the responsible pathologist, and result data has been changed.]
    • Cancelled [The result is unavailable because the test was not started or not completed (also sometimes called 'aborted').]
    • Entered in error [The Test Result has been withdrawn following previous Final release.]
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    • Intra-operative findings [Findings related to tissue examined intra-operatively.]
    • Macroscopic findings [Findings recorded on examination of a gross specimen.]
    • Microscopic findings [Findings recorded after microsopic examination.]
    • Histopathology findings [General histopathology findings.]
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    All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0057], code=at0057, itemType=ELEMENT, level=4, text=Conclusion, description=Concise and clinically contextualised narrative interpretation of the laboratory test results., comment=null, uncommonOntologyItems={fhir_mapping=DiagnosticReport.conclusion}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0098], code=at0098, itemType=ELEMENT, level=4, text=Pathological diagnosis, description=Single word, phrase or brief description representing the narrative in the 'Conclusion'., comment=Coding with a terminology is preferred, where possible., uncommonOntologyItems={fhir_mapping=DiagnosticReport.codedDiagnosis}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0.130], code=at0.130, itemType=SLOT, level=4, text=Staging, description=Details of pathological staging, particularly for malignancy., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0101], code=at0101, itemType=ELEMENT, level=4, text=Comment, description=Additional narrative about the test not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0010], code=at0010, itemType=ELEMENT, level=4, text=Test representation, description=Rich text or other multimedia representation of the entire result as issued by the diagnostic service., comment=Multiple formats are allowed but they must be semantically equivalent., uncommonOntologyItems={fhir_mapping=DiagnosticReport.presentedForm}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_MULTIMEDIA, bindings=null, values=, extendedValues=null]], credentials=[]}, topLevelItems={state=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/state[at0112], code=at0112, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0004], code=at0004, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=3..*, subCardinalityText=Minimum of 3 items, dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0017], code=at0017, itemType=SLOT, level=2, text=Responsible laboratory, description=Demographic details of the laboratory with responsibility for the test., comment=null, uncommonOntologyItems={fhir_mapping=DiagnosticReport.performer}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0068], code=at0068, itemType=ELEMENT, level=2, text=Laboratory test identifier, description=The local identifier given to the laboratory test result by the Laboratory Information System., comment=null, uncommonOntologyItems={fhir_mapping=DiagnosticReport.identifier}, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0094], code=at0094, itemType=CLUSTER, level=2, text=Test request details, description=Details concerning a single laboratory test requested., comment=Usually there is one test request (or "order") for each result, however in some circumstances multiple test requests may be represented using a single Pathology test result archetype., uncommonOntologyItems={fhir_mapping=DiagnosticReport.requestDetail}, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=1..*, cardinalityText=, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0094]/items[at0106], code=at0106, itemType=ELEMENT, level=3, text=Original test requested Name, description=Identification of the original laboratory test requested, where the test requested differs from the test actually performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0094]/items[at0062], code=at0062, itemType=ELEMENT, level=3, text=Requester order identifier, description=The local ID assigned to the test order by the order requester., comment=Equivalent to the HL7 Placer Order Identifier., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0094]/items[at0063], code=at0063, itemType=ELEMENT, level=3, text=Receiver order identifier, description=The local ID assigned to the test order by the order filler, usually by the Laboratory Information System (LIS)., comment=Assigning an identifier to a request by the Laboratory lnformation System (LIS) enables tracking progress of the request and enables linking results to requests. It also provides a reference to assist with enquiries and it is usually equivalent to the HL7 Filler Order Identifier., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_IDENTIFIER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0094]/items[at0090], code=at0090, itemType=SLOT, level=3, text=Requester, description=Details of the clinician or organisation requesting the laboratory test result., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    All not explicitly excluded archetypes, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0094]/items[at0035], code=at0035, itemType=SLOT, level=3, text=Distribution list, description=Details of a clinician or organisation who will receive a copy of the laboratory test result., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    openEHR-EHR-CLUSTER.distribution.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0111], code=at0111, itemType=ELEMENT, level=2, text=Point of care device, description=True if a point of care device supplies the test result rather than a formal laboratory service., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Assumed value: false, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0110], code=at0110, itemType=SLOT, level=2, text=Test method/device details, description=Additional structured details of laboratory test methodology followed. For example, structured details about the laboratory method and data interpretation used., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    openEHR-EHR-CLUSTER.device.v1 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/protocol[at0004]/items[at0117], code=at0117, itemType=SLOT, level=2, text=Extension, description=Slot to allow extension to support localisation or alignment with other standards/ reference models., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include:
    All not explicitly excluded archetypes, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null]