ARCHETYPE Histopathology (openEHR-EHR-OBSERVATION.lab_test-histopathology.v1)

ARCHETYPE ID	openEHR-EHR-OBSERVATION.lab_test-histopathology.v1
Concept	Histopathology
Description	Simple histopathology lab test result.
Use	Normally used only as the basis for further specialisation but is suitable for very simple tests with only a free text conclusion. Will generally be used in combination with archetypes representing other parts of the laboratory test ordering and processing process to form a full lab test report within a Composition. Specimen slots are available in a number of positions to reflect the variation in pathology reporting styles.
Misuse	Do not use for standard itemised value-driven lab tests such as haematology and biochemistry- use OBSERVATION.lab_test. Do not use for microbiology - use OBSERVATION.lab_test-microbiology.
Purpose	Generic entry for an anatomical pathology test or histopathology test . This may be used for very simple reporting formats but will often be specialised or extended via the Structured Detail slots.
References
Copyright	copyright (c) 2010 openEHR foundation
Authors	Author name: Dr Ian McNicoll Organisation: openEHR Archetype Editorial Group / Ocean Informatics Email: ian.mcnicoll@oceaninformatics.com Date originally authored: 27/01/2009
Other Details Language	Author name: Dr Ian McNicoll Organisation: openEHR Archetype Editorial Group / Ocean Informatics Email: ian.mcnicoll@oceaninformatics.com Date originally authored: 27/01/2009
Other Details (Language Independent)	References: MD5-CAM-1.0.1: 3B124686FC94085D4B39B870E80C9CD4
Keywords	lab, pathology, laboratory, histopathology, anatomic pathology, surgical pathology
Lifecycle	AuthorDraft
Language used	en
Citeable Identifier	1013.1.351
events
Any event	Any event: *
protocol
Test identification	Test identification: Unique identifiers used in delivery of the care process.
Placer order identifier	Placer order identifier: The ID assigned to the order by the order requester. Equivalent to the NEHTA Requester Order Identifier.
Filler order Identifier	Filler order Identifier: The ID assigned to the test order by the order filler, usually by the (LIS) Laboratory Information System. Equivalent to the DICOM Accession Number and NEHTA Laboratory Request Identifier.
Laboratory test result identifier	Laboratory test result identifier: The identifier given to the laboratory test result of a pathology investigation.
Laboratory details	Laboratory details : Demographic details of the laboratory with responsibility for the test. Details of secondary laboratories may also be included. Include: openEHR-EHR-CLUSTER.organisation.v1 Exclude: All not explicitly included archetypes
Datetime result issued	Datetime result issued: The date and/or time that the result was issued for the recorded ‘test status’. The date and time related to the results status is useful for version control and cumulative results for the report.
data
Test name	Test name: Specific identifier for this lab test. e.g. Full blood count , blood glucose, urine microbiology. May equate to the result name for a single value result. Commonly a coded term e.g from LOINC or SNOMED-CT.
Diagnostic service	Diagnostic service: The type of high-level diagnostic service e.g. biochemistry, haematology.
Test status	Test status: The status of the lab test as a whole. at0037::Interim [This is an initial or interim result - further updates are anticipated] at0038::Final [This is the final result. No further alterations are anticipated] at0039::Supplementary [This is a supplememtary result in addition to the Interim result] at0040::Corrected (amended) [This is a Correction which should replace any previous results] at0074::Aborted [*] at0079::Never performed [The test was never performed.]
Specimen detail	Specimen detail: Details of the specimen being reported where all individual results are derived from the same specimen Include: openEHR-EHR-CLUSTER.specimen.v1 and specialisations Exclude: All not explicitly included archetypes
Macroscopic findings	Macroscopic findings: Macroscopic findings - more than one set of findings may be recorded.
Macroscopic finding	Macroscopic finding: A single set of macroscopic pathology findings.
Tissue present	Tissue present: Confirmation, or otherwise, that the tissue or structure referred to by this macroscopic finding is present in the specimen for analysis. at0.91::Present [The anatomical structure or tissue is present.] at0.92::Absent [The anatomical structure or tissue is absent]
Macroscopic specimen detail	Macroscopic specimen detail : Details of the macroscopic specimen being reported. Include: openEHR-EHR-CLUSTER.specimen.v1 and specialisations Exclude: All not explicitly included archetypes
Structured macroscopic detail	Structured macroscopic detail : Further structured detail concerning macroscopic findings Include: openEHR-EHR-CLUSTER.macroscopy_colorectal_carcinoma.v1 and specialisations or openEHR-EHR-CLUSTER.macroscopy_lung_carcinoma.v1 and specialisations
Description	Description: Narrative text recorded at the time of specimen macroscopic dissection.
Overall macroscopic description	Overall macroscopic description: General comment or description about macroscopy findings.
Microscopic findings	Microscopic findings: Microscopic findings - more than one set of findings may be recorded.
Microscopic finding	Microscopic finding: Single set of microscopic pathology findings. Usually equates to a single specimen.
Histopathological result	Histopathological result: A conclusion or 'pathological diagnosis' for this individual microscopic finding.
Location	Location: Details of the anatomical location of the microscopic finding being described. Include: openEHR-EHR-CLUSTER.anatomical_location-precise.v1
Size	Size: Details of the size or other physical properties of the microscopic finding. Include: openEHR-EHR-CLUSTER.physical_properties.v1
Microscopic specimen detail	Microscopic specimen detail : Details of a microscopic specimen. Include: openEHR-EHR-CLUSTER.specimen.v1 and specialisations Exclude: All not explicitly included archetypes
Structured microscopic detail	Structured microscopic detail : Further structured detail of microscopic findings, often disease or organ specific. Include: openEHR-EHR-CLUSTER.microscopy_lymphoma.v1 and specialisations or openEHR-EHR-CLUSTER.microscopy_melanoma.v1 and specialisations or openEHR-EHR-CLUSTER.microscopy_lung_carcinoma.v1 and specialisations or openEHR-EHR-CLUSTER.microscopy_breast_carcinoma.v1 and specialisations or openEHR-EHR-CLUSTER.microscopy_colorectal_carcinoma.v1 and specialisations or openEHR-EHR-CLUSTER.microscopy_prostate_carcinoma.v1 and specialisations
Description	Description: Narrative text recorded at the time of specimen microscopic examination.
Overall microscopic description	Overall microscopic description: General comment or description about microscopy findings as a whole.
Pathological Staging	Pathological Staging : Details of pathological staging, particularly for malignancy. Include: openEHR-EHR-CLUSTER.tnm_staging.v1 and specialisations or openEHR-EHR-CLUSTER.tumour_colorectal_staging_non_tnm.v1 and specialisations
Histopathological result	Histopathological result: Conclusions or 'pathological diagnoses' for the whole test.
Histopathological subtype	Histopathological subtype: A subtype of the histopthological result.
Overall interpretation	Overall interpretation: An overall interpretative comment on this test.
Multimedia representation	Multimedia representation: Representations of the whole test in mutlimedia e.g image, audio, video.
Per-result annotation	Per-result annotation: Slot to allow an annotation to be added to a particular test result at run-time. Generally unused in this specialisation. Include: openEHR-EHR-CLUSTER.lab_result_annotation.v1 and specialisations Exclude: All not explicitly included archetypes
Other contributors	Heather Leslie AEG / Ocean Infomatics Sam Heard Ocean Informatics
Translators