A.1 - EHDS refined base model for laboratory report header data elements

Common header for all patient-related data

Patient/subject information

Unique identifier of the document

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of the issuing the document/resource by its author.

Date and time of the last update to the document/information

Status of the resource

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Business version of the resource.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

Document title, such as Hospital Discharge Report, Laboratory Result Report, etc.

The status of the Hospital discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Categorization of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

SNOMED CT

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Related documents and information sources

...

...

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

A.1 - EHDS refined base model for laboratory report header data elements

SNOMED CT

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable

A.1 - EHDS refined base model for laboratory report header data elements

Common header for all patient-related data

Patient/subject information

Unique identifier of the document

Resource authoring details

Author(s) by whom the resource was/were authored. Multiple authors could be provided.

Date and time of the issuing the document/resource by its author.

Date and time of the last update to the document/information

Status of the resource

Reason for the current status of the resource.

Language in which the resource is written. Language is expressed by the IETF language tag.

BCP 47

Business version of the resource.

A narrative easy-to-read representation of the full data set, e.g. PDF-version of a document

Identifies the type of document at hand, e.g. Hospital discharge report.

LOINC

Document title, such as Hospital Discharge Report, Laboratory Result Report, etc.

The status of the Hospital discharge report. E.g., preliminary, final.

hl7:CompositionStatus

Time of service that is being documented

Document attestation details

Attester who validated the document. Mulitple attesters could be provided.

Date and time of the approval of the document by Attester.

Document legal authentication

The person taking responsibility for the medical content of the document

Date and time when the document was authorized.

Categorization of the event covered by the document (e.g. laboratory study types, imaging study types including modality, etc.). Selection of such tags or labels depends on the use case and agreement betwen data sharing parties. This meta-data element serves primarily for searching and filtering purpuses.

SNOMED CT

Additional details about where the content was created (e.g. clinical specialty)

SNOMED CT

Organisation that is in charge of maintaining the document/report.

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

HL7 Document Format Codes

Level of confidentiality of the document. Implicit value is normal.

hl7:Confidentiality

Related documents and information sources

...

...

Health insurance information (Health insurance information is not always required, however, in some jurisdictions, the insurance number is also used as the patient identifier. It is necessary not just for identification but also forms access to funding for care.)

Information recipient (intended recipient or recipients of the report, additional recipients might be identified by the ordering party, e.g. GP, other specialist), if applicable