| ARCHETYPE ID | openEHR-EHR-OBSERVATION.pathology_test-blood_glucose.v1 |
|---|---|
| Concept | Blood Glucose Test Result |
| Description | The findings and interpretation of glucose tests performed on plasma, serum or whole blood. |
| Use | Use to record any glucose test results performed on plasma, serum or whole blood whether measured in a formal laboratory environment, point of care delivery or home monitoring. This archetype has been designed to enable the health record to:
Will normally be reported back to the requesting clinician as one component within the context of an overall COMPOSITION-based report. |
| Misuse | Not to be used to represent an entire cumulative report. This Pathology 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 urine glucose test results - use OBSERVATION.urinalysis. Not to be used to record CSF glucose test results - use the generic OBSERVATION.pathology_test with CSF noted as the biological sample. |
| Purpose | To record the findings and interpretation of glucose tests performed on plasma, serum or whole blood. |
| References | 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. |
| Copyright | © openEHR Foundation |
| Authors | Author name: Ian McNicoll Organisation: Ocean Informatics, United Kingdom Email: ian.mcnicoll@oceaninformatics.com Date originally authored: 2009-11-07 |
| Other Details Language | Author name: Ian McNicoll Organisation: Ocean Informatics, United Kingdom Email: ian.mcnicoll@oceaninformatics.com Date originally authored: 2009-11-07 |
| Other Details (Language Independent) |
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| Keywords | lab, pathology, biochemistry, laboratory, test, specimen |
| Lifecycle | CommitteeDraft |
| Language used | en |
| Citeable Identifier | 1013.1.1440 |
| state | |
| Fasting State | Fasting State: A fasting specimen was used for the measurement. Allowed values: {true} |
| Duration of Fasting | Duration of Fasting: The duration of fasting completed by the test subject prior to the sample being taken. Allowed values: hours, minutes >=0 minutes |
| Glucose Load | Glucose Load: The amount of glucose administered to the test subject. Property: Mass Units:
|
| Insulin Load | Insulin Load: The amount of insulin administered to the test subject. Property: Mass (IU) Units: IU Limit decimal places: 0 |
| events | |
| Any event | Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time. |
| Baseline Measurement | Baseline Measurement: Specific point in time measurement which provides a reference glucose reading against which subsequent measurements can be compared. Offset: 0 minutes |
| 1 Hour Measurement | 1 Hour Measurement: Specific point in time measurement taken 1 hour after the Baseline Measurement and subsequent glucose/insulin challenge. Offset: 1 hour |
| 2 Hour Measurement | 2 Hour Measurement: Specific point in time measurement taken 2 hours after the Baseline Measurement and subsequent glucose/insulin challenge. Offset: 2 hours |
| Pre-prandial Measurement | Pre-prandial Measurement: Measurement taken before a meal. |
| Post-prandial Measurement | Post-prandial Measurement: Measurement taken after a meal. |
| protocol | |
| Point of Care Device Used | Point of Care Device Used: The test was performed using a point of care device or a home-based device. Allowed values: {true} |
| Route of Administration | Route of Administration: Route that the glucose was administered.
|
| Testing Device | Testing Device: The device used to test the specimen. For example: home glucometer. Include: openEHR-EHR-CLUSTER.device.v1 and specialisations |
| Receiving Laboratory | Receiving Laboratory: Demographic details of the laboratory with responsibility for the pathology test. Include: All not explicitly excluded archetypes |
| Test Request Details | Test Request Details: Details concerning a single pathology test requested. 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. |
| Requester Order Identifier | Requester Order Identifier: The local ID assigned to the order by the order requester. Equivalent to the Placer Order Identifier. |
| Test Requested Name | Test Requested Name: Identification of pathology test requested, where the test requested differs from the test actually performed. |
| Requester | Requester: Details of the clinician or organisation requesting the pathology test result. Include: All not explicitly excluded archetypes |
| Copied Provider | Copied Provider: Details of the clinician or organisation who will receive a copy of the pathology test result. Include: All not explicitly excluded archetypes |
| Receiver Order Identifier | Receiver Order Identifier: The local ID assigned to the test order by the order filler, usually by the Laboratory Information System (LIS). Assigning an identifier to a request by the Radiology lnformation System 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. |
| Laboratory Test Result Identifier | Laboratory Test Result Identifier: The identifier given to the laboratory test result of a pathology investigation. |
| Test Procedure | Test Procedure: Additional structured details of pathology test methodology followed. For example, structured details about the laboratory method and data interpretation used. Include: All not explicitly excluded archetypes |
| data | |
| Test Result Name | Test Result Name: Identification of the pathology test performed, sometimes including specimen type and patient state. A test result may be for a single analyte, or a group of items, including panel tests. Coding with a terminology, potientially a pre-coordinated term including specimen type, is preferred, where possible. May be coded with LOINC or Snomed-CT. Examples include "Glucose", "Urea and Electrolytes", "Swab", “Cortisol (am)” or "Liver Biopsy". |
| Diagnostic Service | Diagnostic Service: The diagnostic service that performs the examination. For example, biochemistry, haematology. Coding with a terminology is desirable, where possible. |
| Specimen Detail | Specimen Detail: Details about the specimen if all individual test results are derived from the same specimen. If the specimen type is sufficiently specified with a code in the Test result name, then this additional data is not required. If there are multiple specimens, these may be represented per 'Result group'. Include: openEHR-EHR-CLUSTER.specimen.v1 and specialisations |
| Overall Test Result Status | Overall Test Result Status: The publication status of the entire pathology test result.
|
| DateTime Result Issued | DateTime Result Issued: The date and/or time that the entire result was issued for the recorded ‘Overall Test result status’. |
| Clinical Information Provided | Clinical Information Provided: Description of clinical information available at the time of interpretation of results, which may include a link to the original clinical information provided in the test request. |
| Result Group | Result Group: A group of results. If a name or code is used, it is provided by run-time re-naming of the Results may be grouped by specimen, or by some other name or code to describe what binds all the results together. 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. |
| Result | Result: Specific detailed result, including both the value of the result item, and additional information that may be useful for clinical interpretation. Results include whatever specific data items pathology labs report as part of the clinical service; it is not confined to measurements. The result is identified by run-time re-naming of the 'Result group' element or may be fixed in a specialised archetype or template. Coding with a terminology, potentially a pre-coordinated term including specimen type, is preferred where possible for the name. Should be coded with LOINC or SNOMED CT. Examples include: glucose, haemoglobin, phenotype, titre, or scatterplot image. If the test result is for a single analyte, then both the "Test Result Name" and the "Result" item will specify the same test. |
| Glucose Result | Glucose Result: Actual value of the glucose test result. Property: Concentration Units:
|
| Result Comment | Result Comment: Comment about the Result. May include statements about significant, unexpected or unreliable. values, or information about the source of the value where this may be relevant to the interpretation of the result. |
| Reference Range Guidance | Reference Range Guidance: Additional advice on the applicability of the reference range. |
| Result Value Status | Result Value Status: The status of the result value. Allows a single test result to contain multiple individual results each with their own status.
|
| Specimen Detail | Specimen Detail: Details about the individual specimen to which these ‘Result group’ test results refer, where testing of multiple specimens is required. Include: openEHR-EHR-CLUSTER.specimen.v1 and specialisations |
| Conclusion | Conclusion: Concise and clinically contextualised narrative interpretation of the pathology test results. |
| Pathological Diagnosis | Pathological Diagnosis: Single word, phrase or brief description representing the narrative in the 'Conclusion'. Coding with a terminology is preferred, where possible. |
| Test Result Representation | Test Result Representation: Rich text representation of the entire result as issued by the diagnostic service. Multiple formats are allowed but they must be semantically equivalent. text/html, text/plain, text/rtf, application/msword, application/pdf, application/rtf, application/vnd. |
| Test Comment | Test Comment: Additional narrative about the test not captured in other fields. |
| Other contributors | 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 |
| Translators |