ARCHETYPE Microbiolology of cerebro-spinal fluid (openEHR-EHR-OBSERVATION.lab_test-microbiology-csf.v1)

ARCHETYPE ID	openEHR-EHR-OBSERVATION.lab_test-microbiology-csf.v1
Concept	Microbiolology of cerebro-spinal fluid
Description	Cerebro-spinal fluid microbiology test result.
Use	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. Specific tests will gnerally require further specialisation or templating constraint.
Misuse	Do not use for standard value-driven lab tests such as haematology and biochemistry tests. Do not use for other bodily fluid microbiology results.
Purpose	To record cerebro-spinal fluid microbiology lab test result.
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: B645C899634175CF2975C90E48D62EBD
Keywords	lab, pathology, microbiology, laboratory, csf, cerebrospinal
Lifecycle	AuthorDraft
Language used	en
Citeable Identifier	1013.1.687
events
Any event	Any event: *
protocol
Requestor order identifier	Requestor order identifier: The local ID assigned to the order by the order requester. Equivalent to the Placer Order Identifier.
Requestor	Requestor : Details of the clinician or organisation requesting the laboratory test. 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 (LIS) Laboratory Information System. Equivalent to the DICOM Accession Number and the Filler Order Identifier.
Receiving laboratory	Receiving laboratory : 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
Laboratory test result identifier	Laboratory test result identifier: The identifier given to the laboratory test result of a pathology investigation.
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.
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.]
Diagnostic service	Diagnostic service: The type of high-level diagnostic service e.g. biochemistry, haematology.
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
Macroscopic findings	Macroscopic findings: Findings on macroscopic examination.
Colony count	Colony count: The count of colonies min: >=0
Macroscopic result	Macroscopic result: The result of the macroscopic aspect of the test.
Description	Description: Description of macroscopic findings
Microscopic findings	Microscopic findings: Findings on microscopic examination.
Field count	Field count: Microscopy field count min: >=0
Gram smear result	Gram smear result: Findings on gram smear testing.
Microscopic result	Microscopic result: The result of the microscopic aspect of the test.
Description	Description: Description of the microscopic findings
Bodily fluid findings	Bodily fluid findings: Findings related to a bodily fluid specimen.
Fluid details	Fluid details: Details of the bodily fluid being examined. Include: openEHR-EHR-CLUSTER.fluid.v1 and specialisations
Red cell count	Red cell count: Red blood cell count in the bodily fluid.. Property: Concentration Units: >=0.0 10*6/l
White cell count	White cell count: White blood cell count in the bodily fluid. Property: Concentration Units: >=0.0 10*6/l
Lymphocyte count	Lymphocyte count: Count of lymphocytes found in cerebro-spinal fluid. Property: Concentration Units: >=0.0 10*6/l
Polymorphonucleocyte (PNM) count	Polymorphonucleocyte (PNM) count: The cell count of polymorphonucleocytes in the cerebro-spinal fluid Property: Concentration Units: >=0.0 10*6/l
Protein	Protein: Concentration of protein in the cerebro-spinal fluid. Property: Concentration Units: >=0.0 gm/l
Glucose CSF:serum ratio	Glucose CSF:serum ratio: The CSF:serum ratio of glucose. Ratio Percent Numerator: >=0.0 Assumed value: false
Description	Description: Text description of bodily fluid findings.
Culture findings	Culture findings: Findings on specimen culture.
Culture method	Culture method: The method of culturing, may be multiple e.g. aerobic and anaerobic cultures. Unbounded as all culture methods may be reported as a combined result or reported singly.
Growth duration	Growth duration: Duration of growth.
Beta lactamase	Beta lactamase: Beta-lactamase result(s).
Culture result	Culture result: Results relating to microbial culture.
Description	Description: A description of the overall culture finding.
Microbial findings	Microbial findings: Multiple results obtained from the culture, normally per-microbe.
Organism	Organism: The name of the organism identified.
Biotype	Biotype: The organism biotype.
Microbial result	Microbial result: Records other findings related to organisms e.g protein-typing.
Description	Description: Information specific to a specific microbial finding.
Therapeutic sensitivities	Therapeutic sensitivities: The name of the anti-microbial agent against which the organism was tested for susceptabiliity.
Agent	Agent: Name of the anti-microbial agent.
Sensitivity	Sensitivity: Coded sensitivity at0.11::Sensitive [The microbe is sensitive to the therapeutic agent] at0.12::Resistant [The microbe is resistant to the theraputic agent.] at0.13::Borderline resistant [The microbe is borderline resistant to the therapeutic agent]
Quantified sensitivity	Quantified sensitivity: A measure of the sensitivity based on a quantifiable method such as the Minimum Inhhibitory Concentration (MIC). Property: Concentration
Method of sensitivity	Method of sensitivity: Method used to determine sensitivity.
Antimicrobial advice	Antimicrobial advice: A text description of antimicrobial advice such as dosing, pharmacokinetic issues, and drug costings.
Notifications	Notifications: * Include: openEHR-EHR-CLUSTER.notifiable_condition.v1 and specialisations or openEHR-EHR-CLUSTER.outbreak_identification.v1 and specialisations or openEHR-EHR-CLUSTER.case_identification.v1 and specialisations
Result	Result: The result of the test.
Per-result annotation	Per-result annotation: Slot to allow an annotation to be added to a particular test result at run-time. Include: openEHR-EHR-CLUSTER.lab_result_annotation.v1 and specialisations
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.
Other contributors	Heather Leslie AEG / Ocean Infomatics Sam Heard Ocean Informatics
Translators