HdBe-TekstUitslag
WARNING This page contains a draft CBB, as raw output from the zib export and automatic conversion to CBB. It requires thorough review and adaption to the Belgian realm. This CBB is merely added for informative use.
CBB | Concept | Status |
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HdBe-TextResult | Een tekstuitslag beschrijft de bevindingen en interpretatie van diagnostische of therapeutische verrichtingen, uitgevoerd op patiënten of monsters afkomstig van de patiënt. PurposeHet vastleggen van de resultaten van diagnostische verrichtingen ten behoeve van communicatie hiervan met de aanvrager van de verrichting en het documenteren van de bevindingen naar aanleiding van therapeutische verrichtingen. Evidence BaseDe meeste uitslagen van verrichtingen en sommige uitslagen van laboratorium onderzoeken zijn verhalend van aard. Het gaat hierbij om o.a. verslagen van radiologie, pathologie, scopieën, echografie, etc en laboratoriumonderzoeken als banale kweken, waar uitslag, interpretatie en advies integraal onderdeel uitmaken van de uitslag. Deze bouwsteen kan gebruikt worden voor deze niet verder gestructureerde uitslagen. Bij uitslagen van laboratoriumbepalingen is het moeilijk eenduidig aan te geven wanneer deze bouwsteen gebruikt moet worden en wanneer de bouwsteen LaboratoriumUitslag gebruikt moet worden. In het algemeen worden laboratoriumtesten die resulteren in een waarde (7,1 mmol/L), rangtelwoord (++ uit reeks tot ++++) of een kwantitatieve uitslag (Weinig) het beste overgedragen met LaboratoriumUitslag en is deze bouwsteen meer geschikt voor tekstuele uitslagen die langer dan een paar woorden zijn. In vrijwel alle laboratoria komen beide soorten testen voor. De toepasbaarheid wordt niet door het soort lab maar door het soort uitslag bepaald. | draft |
TextResult | TextResult | ||
id | 0..1 | string | |
extension | I | 0..* | Extension |
TextResultDateTime | 0..1 | dateTime | |
Procedure | I | 0..1 | Reference(HdBe-Procedure) |
TextResultStatus | 0..1 | CodeableConceptBinding | |
TextResultReport | 1..1 | string | |
VisualResult | 0..* | base64Binary | |
TextResultType | 1..1 | CodeableConceptBinding |
TextResult | 0..* | |
TextResult.TextResultDateTime | dateTime | 0..1 |
TextResult.Procedure | Reference(HdBe-Procedure) | 0..1 |
TextResult.TextResultStatus | CodeableConcept | 0..1 |
TextResult.TextResultReport | string | 1..1 |
TextResult.VisualResult | base64Binary | 0..* |
TextResult.TextResultType | CodeableConcept | 1..1 |
TextResult | |
Definition | Root concept of the TextResult information model. This root concept contains all data elements of the TextResult information model. |
Cardinality | 0...* |
Invariants |
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Mappings |
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TextResult.id | |
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
Cardinality | 0...1 |
Type | string |
Mappings |
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TextResult.extension | |
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
Cardinality | 0...* |
Type | Extension |
Alias | extensions, user content |
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
Slicing | Unordered, Open, by url(Value) |
Invariants |
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Mappings |
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TextResult.TextResultDateTime | |
Definition | Date and if possible time of the result report. |
Cardinality | 0...1 |
Type | dateTime |
Invariants |
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Mappings |
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TextResult.Procedure | |
Definition | Reference to the Procedure information model including the date of the procedure, requesting and executive specialty. |
Cardinality | 0...1 |
Type | Reference(HdBe-Procedure) |
Comments | References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. |
Invariants |
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Mappings |
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TextResult.TextResultStatus | |
Definition | The status of the result. |
Cardinality | 0...1 |
Type | CodeableConcept |
Binding | TextResultStatus codes |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. |
Invariants |
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Mappings |
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TextResult.TextResultReport | |
Definition | The text report detailing the actual results of the test or procedure. |
Cardinality | 1...1 |
Type | string |
Comments | Note that FHIR strings SHALL NOT exceed 1MB in size |
Invariants |
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Mappings |
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TextResult.VisualResult | |
Definition | Visual examination results that are the starting point and reason for the textual report. These results include visual material - e.g. radiological images, scopy images, medical photos and videos - as well as graphic recordings - e.g. ECGs, EEGs etc. |
Cardinality | 0...* |
Type | base64Binary |
Comments | A stream of bytes, base64 encoded |
Invariants |
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Mappings |
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TextResult.TextResultType | |
Definition | The type of result. |
Cardinality | 1...1 |
Type | CodeableConcept |
Binding | TextResultType codes |
Comments | Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. |
Invariants |
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Mappings |
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Example instances
[CBB name] | |
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[Concept name ] | [example value] |
// example of NameInformation
## Example instances
| NameInformation | |
|----------------------|-------------------|
| FirstNames | Johanna Petronella Maria
| Initials | J.P.M.
| GivenName | Jo
| NameUsage | Geslachtsnaam partner gevolgd door eigen geslachtsnaam
| LastName.Prefix | van
| LastName.LastName | Putten
| LastNamePartner.PartnerPrefix | van der
| LastNamePartner.PartnerLastName | Giessen
| Titles |
zib [zib name + version](https://zibs.nl/wiki/[zib name + version(release)]) difference
Concept | Category | Description |
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[element.path] |
[category of change] | [Description of change]([Reference to ticket/issue/zulip chat using MarkDown link]) |
Terminology Bindings
Path | Name | Strength | URL |
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TextResultStatus | TextResultStatus | extensible | https://fhir.healthdata.be/ValueSet/TextResultStatus |
TextResultType | TextResultType | extensible | https://fhir.healthdata.be/ValueSet/TextResultType |