archetype (adl_version=1.4) openEHR-EHR-OBSERVATION.lab_test-histopathology.v1 specialise openEHR-EHR-OBSERVATION.lab_test.v1 concept [at0000.1] -- Histopathology language original_language = <[ISO_639-1::en]> description original_author = < ["name"] = <"Dr Ian McNicoll"> ["organisation"] = <"openEHR Archetype Editorial Group / Ocean Informatics"> ["email"] = <"ian.mcnicoll@oceaninformatics.com"> ["date"] = <"27/01/2009"> > details = < ["en"] = < language = <[ISO_639-1::en]> 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."> 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. "> keywords = <"lab", "pathology", "laboratory", "histopathology", "anatomic pathology", "surgical pathology"> 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."> copyright = <"copyright (c) 2010 openEHR foundation"> > > lifecycle_state = <"AuthorDraft"> other_contributors = <"Heather Leslie AEG / Ocean Infomatics", "Sam Heard Ocean Informatics"> other_details = < ["MD5-CAM-1.0.1"] = <"3B124686FC94085D4B39B870E80C9CD4"> ["references"] = <""> > definition OBSERVATION[at0000.1] matches { -- Histopathology data matches { HISTORY[at0001] matches { -- Event Series events cardinality matches {1..*; unordered} matches { EVENT[at0002] occurrences matches {0..1} matches { -- Any event data matches { ITEM_TREE[at0003] matches { -- Tree items cardinality matches {0..*; unordered} matches { ELEMENT[at0005] occurrences matches {0..1} matches { -- Test name value matches { DV_TEXT matches {*} } } ELEMENT[at0077] occurrences matches {0..1} matches { -- Diagnostic service value matches { DV_TEXT matches {*} } } ELEMENT[at0073] occurrences matches {0..1} matches { -- Test status value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0037, -- Interim at0038, -- Final at0039, -- Supplementary at0040, -- Corrected (amended) at0074, -- Aborted at0079] -- Never performed } } } } allow_archetype CLUSTER[at0065] occurrences matches {0..*} matches { -- Specimen detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v1/} exclude archetype_id/value matches {/.*/} } CLUSTER[at0.86] occurrences matches {0..1} matches { -- Macroscopic findings items cardinality matches {0..*; unordered} matches { CLUSTER[at0.76] occurrences matches {0..*} matches { -- Macroscopic finding items cardinality matches {0..*; unordered} matches { ELEMENT[at0.90] occurrences matches {0..1} matches { -- Tissue present value matches { DV_CODED_TEXT matches { defining_code matches { [local:: at0.91, -- Present at0.92] -- Absent } } } } allow_archetype CLUSTER[at0.78] occurrences matches {0..*} matches { -- Macroscopic specimen detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v1/} exclude archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0.79] occurrences matches {0..*} matches { -- Structured macroscopic detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.macroscopy_colorectal_carcinoma(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.macroscopy_lung_carcinoma(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0.77] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } } } ELEMENT[at0.88] occurrences matches {0..1} matches { -- Overall macroscopic description value matches { DV_TEXT matches {*} } } } } CLUSTER[at0.87] occurrences matches {0..1} matches { -- Microscopic findings items cardinality matches {0..*; unordered} matches { CLUSTER[at0.81] occurrences matches {0..*} matches { -- Microscopic finding items cardinality matches {0..*; unordered} matches { ELEMENT[at0078.2] occurrences matches {0..1} matches { -- Histopathological result value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0.98] occurrences matches {0..*} matches { -- Location include archetype_id/value matches {/openEHR-EHR-CLUSTER\.anatomical_location-precise\.v1/} } allow_archetype CLUSTER[at0.97] occurrences matches {0..*} matches { -- Size include archetype_id/value matches {/openEHR-EHR-CLUSTER\.physical_properties\.v1/} } allow_archetype CLUSTER[at0.83] occurrences matches {0..*} matches { -- Microscopic specimen detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.specimen(-[a-zA-Z0-9_]+)*\.v1/} exclude archetype_id/value matches {/.*/} } allow_archetype CLUSTER[at0.84] occurrences matches {0..*} matches { -- Structured microscopic detail include archetype_id/value matches {/openEHR-EHR-CLUSTER\.microscopy_lymphoma(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.microscopy_melanoma(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.microscopy_lung_carcinoma(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.microscopy_breast_carcinoma(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.microscopy_colorectal_carcinoma(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.microscopy_prostate_carcinoma(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0.82] occurrences matches {0..1} matches { -- Description value matches { DV_TEXT matches {*} } } } } ELEMENT[at0.89] occurrences matches {0..1} matches { -- Overall microscopic description value matches { DV_TEXT matches {*} } } } } allow_archetype CLUSTER[at0.95] occurrences matches {0..*} matches { -- Pathological Staging include archetype_id/value matches {/openEHR-EHR-CLUSTER\.tnm_staging(-[a-zA-Z0-9_]+)*\.v1|openEHR-EHR-CLUSTER\.tumour_colorectal_staging_non_tnm(-[a-zA-Z0-9_]+)*\.v1/} } ELEMENT[at0078.1] occurrences matches {0..*} matches { -- Histopathological result value matches { DV_TEXT matches {*} } } ELEMENT[at0.100] occurrences matches {0..1} matches { -- Histopathological subtype value matches { DV_TEXT matches {*} } } ELEMENT[at0057] occurrences matches {0..1} matches { -- Overall interpretation value matches { DV_TEXT matches {*} } } ELEMENT[at0010] occurrences matches {0..*} matches { -- Multimedia representation value matches { DV_MULTIMEDIA matches { media_type matches {[openEHR::]} } } } allow_archetype CLUSTER[at0089] occurrences matches {0..*} matches { -- Per-result annotation include archetype_id/value matches {/openEHR-EHR-CLUSTER\.lab_result_annotation(-[a-zA-Z0-9_]+)*\.v1/} exclude archetype_id/value matches {/.*/} } } } } } } } } protocol matches { ITEM_TREE[at0004] matches { -- Tree items cardinality matches {0..*; unordered} matches { CLUSTER[at0013] occurrences matches {0..1} matches { -- Test identification items cardinality matches {0..*; unordered} matches { ELEMENT[at0062] occurrences matches {0..1} matches { -- Placer order identifier value matches { DV_TEXT matches {*} } } ELEMENT[at0063] occurrences matches {0..1} matches { -- Filler order Identifier value matches { DV_TEXT matches {*} } } ELEMENT[at0068] occurrences matches {0..1} matches { -- Laboratory test result identifier value matches { DV_TEXT matches {*} } } allow_archetype CLUSTER[at0017] occurrences matches {0..*} matches { -- Laboratory details include archetype_id/value matches {/openEHR-EHR-CLUSTER\.organisation\.v1/} exclude archetype_id/value matches {/.*/} } } } ELEMENT[at0075] occurrences matches {0..1} matches { -- Datetime result issued value matches { DV_DATE_TIME matches {*} } } } } } } ontology term_definitions = < ["en"] = < items = < ["at0.100"] = < text = <"Histopathological subtype"> description = <"A subtype of the histopthological result."> > ["at0.76"] = < text = <"Macroscopic finding"> description = <"A single set of macroscopic pathology findings."> > ["at0.77"] = < text = <"Description"> description = <"Narrative text recorded at the time of specimen macroscopic dissection."> > ["at0.78"] = < text = <"Macroscopic specimen detail "> description = <"Details of the macroscopic specimen being reported."> > ["at0.79"] = < text = <"Structured macroscopic detail "> description = <"Further structured detail concerning macroscopic findings"> > ["at0.81"] = < text = <"Microscopic finding"> description = <"Single set of microscopic pathology findings. Usually equates to a single specimen."> > ["at0.82"] = < text = <"Description"> description = <"Narrative text recorded at the time of specimen microscopic examination."> > ["at0.83"] = < text = <"Microscopic specimen detail "> description = <"Details of a microscopic specimen."> > ["at0.84"] = < text = <"Structured microscopic detail "> description = <"Further structured detail of microscopic findings, often disease or organ specific."> > ["at0.86"] = < text = <"Macroscopic findings"> description = <"Macroscopic findings - more than one set of findings may be recorded."> > ["at0.87"] = < text = <"Microscopic findings"> description = <"Microscopic findings - more than one set of findings may be recorded."> > ["at0.88"] = < text = <"Overall macroscopic description"> description = <"General comment or description about macroscopy findings."> > ["at0.89"] = < text = <"Overall microscopic description"> description = <"General comment or description about microscopy findings as a whole."> > ["at0.90"] = < text = <"Tissue present"> description = <"Confirmation, or otherwise, that the tissue or structure referred to by this macroscopic finding is present in the specimen for analysis."> > ["at0.91"] = < text = <"Present"> description = <"The anatomical structure or tissue is present."> > ["at0.92"] = < text = <"Absent"> description = <"The anatomical structure or tissue is absent"> > ["at0.95"] = < text = <"Pathological Staging "> description = <"Details of pathological staging, particularly for malignancy."> > ["at0.96"] = < text = <"Size and location"> description = <"Details of size of one or more components of a single microscopy report e.g details of one or more tumour locations within a single tissue such as lung"> > ["at0.97"] = < text = <"Size"> description = <"Details of the size or other physical properties of the microscopic finding."> > ["at0.98"] = < text = <"Location"> description = <"Details of the anatomical location of the microscopic finding being described."> > ["at0000"] = < text = <"Laboratory test"> description = <"To record the result of a laboratory test which may be used to record a single valued test but will often be specialised or templated to represent multiple value or 'panel' tests. This archetype also acts as the parent for specialisations appropriate for more specific laboratory tests microbiology, histopathology."> > ["at0000.1"] = < text = <"Histopathology"> description = <"Simple histopathology lab test result."> > ["at0001"] = < text = <"Event Series"> description = <"@ internal @"> > ["at0002"] = < text = <"Any event"> description = <"*"> > ["at0003"] = < text = <"Tree"> description = <"@ internal @"> > ["at0004"] = < text = <"Tree"> description = <"@ internal @"> > ["at0005"] = < text = <"Test name"> description = <"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."> > ["at0010"] = < text = <"Multimedia representation"> description = <"Representations of the whole test in mutlimedia e.g image, audio, video."> > ["at0013"] = < text = <"Test identification"> description = <"Unique identifiers used in delivery of the care process."> > ["at0017"] = < text = <"Laboratory details "> description = <"Demographic details of the laboratory with responsibility for the test. Details of secondary laboratories may also be included."> > ["at0037"] = < text = <"Interim"> description = <"This is an initial or interim result - further updates are anticipated"> > ["at0038"] = < text = <"Final"> description = <"This is the final result. No further alterations are anticipated"> > ["at0039"] = < text = <"Supplementary"> description = <"This is a supplememtary result in addition to the Interim result"> > ["at0040"] = < text = <"Corrected (amended)"> description = <"This is a Correction which should replace any previous results"> > ["at0057"] = < text = <"Overall interpretation"> description = <"An overall interpretative comment on this test."> > ["at0062"] = < text = <"Placer order identifier"> description = <"The ID assigned to the order by the order requester. Equivalent to the NEHTA Requester Order Identifier."> > ["at0063"] = < text = <"Filler order Identifier"> description = <"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."> > ["at0065"] = < text = <"Specimen detail"> description = <"Details of the specimen being reported where all individual results are derived from the same specimen"> > ["at0068"] = < text = <"Laboratory test result identifier"> description = <"The identifier given to the laboratory test result of a pathology investigation."> > ["at0073"] = < text = <"Test status"> description = <"The status of the lab test as a whole."> > ["at0074"] = < text = <"Aborted"> description = <"*"> > ["at0075"] = < text = <"Datetime result issued"> description = <"The date and/or time that the result was issued for the recorded ‘test status’. "> comment = <"The date and time related to the results status is useful for version control and cumulative results for the report."> > ["at0077"] = < text = <"Diagnostic service"> description = <"The type of high-level diagnostic service e.g. biochemistry, haematology. "> > ["at0078"] = < text = <"Result"> description = <"The result of the test."> > ["at0078.1"] = < text = <"Histopathological result"> description = <"Conclusions or 'pathological diagnoses' for the whole test."> > ["at0078.2"] = < text = <"Histopathological result"> description = <"A conclusion or 'pathological diagnosis' for this individual microscopic finding."> > ["at0079"] = < text = <"Never performed"> description = <"The test was never performed."> > ["at0089"] = < text = <"Per-result annotation"> description = <"Slot to allow an annotation to be added to a particular test result at run-time. Generally unused in this specialisation."> > > > >