Textual results describe the findings and interpretation of diagnostic or therapeutic procedures carried out on patients or on specimens from the patient.

Purpose

Recording the results of diagnostic procedures for the purpose of communicating these with the person requesting the procedure and documenting the findings resulting from therapeutic procedures.

Evidence Base

Most results of procedures and some laboratory test results are descriptive by nature. This includes reports from radiology, pathology, scopies, ultrasounds, etc. and laboratory tests such as cultures, in which results, interpretation and advice form integral parts of the result. This information model can be used for these (mainly unstructured) results.

For laboratory test results, it is difficult to clearly indicate exactly when to use this information model and when to use the LaboratoryTestResult information model. In general, laboratory tests resulting in a value (7.1 mmol/L), ordinal number (++ from series to ++++) or a quantitative result (Low) can best be transferred using the LaboratoryTestResult, whereas this information model is better suited for textual results containing more than just a few words. Both types of tests occur in almost all laboratories. Applicability is not determined by the kind of lab but by the kind of result.