CH LAB-Order (R4)
2.0.0-ballot - ballot Switzerland flag

This page is part of the CH LAB-Order (R4) (v2.0.0-ballot: STU 2 Ballot 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Example Bundle: Referral 1-tvt

Laboratory Order

Case study 1: Suspicion of deep vein thrombosis

A patient, Hans Guggindieluft, presents to Dr. med. Marc Mustermann at the Olten group practice on 09.03.2016. He verbally identifies himself via his master data as Hans Guggindieluft, 01.01.1981. He reports unclear leg pain in the left lower leg as well as simultaneously occurring respiratory pain and cough. The doctor carries out the anamnesis and physical examination and prescribes the following laboratory parameters:

  • Blood cell count incl. differentiation
  • CRP
  • D-dimer

The doctor carries out the Blood count and the CRP determination himself by means of point of care diagnostics, the D-dimer diagnostics is prescribed as quantitative diagnostics in an external sending laboratory. To obtain the sample, a Blood sample is taken lying down (1 EDTA tube, 2 citrate tubes of 5 ml). The order is transmitted to the external laboratory and the sample is sent to the external dispatch laboratory by courier ordered by telephone. The results of the internal point of care diagnostics (Blood count and CRP) are entered in the patient`s laboratory sheet in the doctor`s office software (manually or via locally installed electronic interfaces). A prescription is therefore issued by the doctor to the patient for self-administration of an anti-thrombotic agent. The results of the sending-in laboratory arrive electronically at the GP`s on the same evening and are also entered in the patient`s laboratory sheet. By using the present exchange format, this process can be fully automated. After a telephone enquiry by the doctor at the sending laboratory due to a borderline D-dimer result, the information is given that a deep vein thrombosis cannot be ruled out in this situation by means of D-dimer and the patient is therefore called back the next day for a sonography of the legs.

Matching FHIR questionnaire that meets this specification: 1-tvt.xml 1-tvt.json

As it is probably a primary leg vein thrombosis, Dr Eva Erlenmeier from the Pipette laboratory sends feedback to Dr Mustermann with the recommendation to carry out a thrombophilia screening, which includes the following analyses: Quick, aPTT, fibrinogen, antithrombin (funct.), thrombin time I 2.5 NIH/ml, APC resistance, D-dimers, protein C, (aPTT method), protein S antigen. The analyses can be carried out directly from the samples of the citrate tubes sent along.

Order-Referral-Form 1-tvt

Order-Referral-Form 1-tvt

Additional Document Content

2. http://example.com/fhir/Patient/HansGuggindieluft (Patient/HansGuggindieluft)

id: HansGuggindieluft

meta:

identifier: 012/08.111111

name: Hans Guggindieluft

gender: MALE

birthDate: Jan 01, 1981

maritalStatus: unverheiratet (Details : {$ech-11-maritalstatus code '5' = '5', given as 'unverheiratet'})

Communications

-LanguagePreferred
*Deutsch (Schweiz) (Details : {urn:ietf:bcp:47 code 'de-CH' = 'German (Region=Schweiz))true

3. http://example.com/fhir/Practitioner/MarcMustermann (Practitioner/MarcMustermann)

Generated Narrative: Practitioner

Resource Practitioner "MarcMustermann"

Profile: CH Core Practitioner

identifier: id: 7601000050700, id: A123309

name: Marc Mustermann (OFFICIAL)

telecom: ph: 033 333 22 11(WORK), marc.mustermann@gruppenpraxis.ch

4. http://example.com/fhir/Organization/Arztpraxis (Organization/Arztpraxis)

Generated Narrative: Organization

Resource Organization "Arztpraxis"

Profile: CH Core Organization

identifier: id: 7601000235503

name: Arztpraxis Messen

Contacts

-TelecomAddress
*+41555545566, info@arztpraxis.ch, http://www.arztpraxis.chDoktorgasse 2 Messen 3254 CH

5. http://example.com/fhir/PractitionerRole/MarcMustermannArztpraxis (PractitionerRole/MarcMustermannArztpraxis)

Generated Narrative: PractitionerRole

Resource PractitionerRole "MarcMustermannArztpraxis"

Profile: CH Core PractitionerRole

practitioner: See above (Practitioner/MarcMustermann)

organization: See above (Organization/Arztpraxis)

6. http://example.com/fhir/Questionnaire/1-tvt (Questionnaire/1-tvt)

Structure

LinkIdTextCardinalityTypeFlagsDescription & Constraintsdoco
.. LabOrderFormExampleQuestionnairehttp://fhir.ch/ig/ch-lab-order/Questionnaire/1-tvt#1.0.0
... orderAuftrag1..1group
.... order.placerOrderIdentifierAuftragsnummer des Auftraggebers0..1string
.... order.placerOrderIdentifierDomainIdentifier Domain der Auftragsnummer des Auftraggebers0..1stringicon
.... order.fillerOrderIdentifierAuftragsnummer des Auftragsempfängers0..1string
.... order.fillerOrderIdentifierDomainIdentifier Domain der Auftragsnummer des Auftragsempfängers0..1stringicon
.... order.precedentDocumentIdentifierIdentifier des Vorgängerdokuments0..1stringicon
.... order.notificationContactDocumentDringender Benachrichtigungskontakt für dieses Dokument0..1group
..... order.notificationContactDocument.practitionerZu benachrichtigende Person0..1group
...... order.notificationContactDocument.practitioner.titleTitel0..1string
...... order.notificationContactDocument.practitioner.familyNameName0..1string
...... order.notificationContactDocument.practitioner.givenNameVorname0..1string
...... order.notificationContactDocument.practitioner.phoneTelefon0..1string
...... order.notificationContactDocument.practitioner.emailE-Mail0..1string
.... order.notificationContactDocumentResponseDringender Benachrichtigungskontakt für die Antwort auf dieses Dokument0..1group
..... order.notificationContactDocumentResponse.practitionerZu benachrichtigende Person0..1group
...... order.notificationContactDocumentResponse.practitioner.titleTitel0..1string
...... order.notificationContactDocumentResponse.practitioner.familyNameName0..1string
...... order.notificationContactDocumentResponse.practitioner.givenNameVorname0..1string
...... order.notificationContactDocumentResponse.practitioner.phoneTelefon0..1string
...... order.notificationContactDocumentResponse.practitioner.emailE-Mail0..1string
.... order.priorityAuftragspriorität0..1choiceOptions: 4 options
... receiverEmpfänger0..1group
.... receiver.practitionerEmpfangende Person0..1group
..... receiver.practitioner.titleTitel0..1string
..... receiver.practitioner.familyNameName0..1string
..... receiver.practitioner.givenNameVorname0..1string
..... receiver.practitioner.glnGLN0..1string
..... receiver.practitioner.zsrZSR0..1string
..... receiver.practitioner.phoneTelefon0..1string
..... receiver.practitioner.emailE-Mail0..1string
.... receiver.organizationEmpfangende Organisation0..1group
..... receiver.organization.nameName der Organisation0..1string
..... receiver.organization.glnGLN0..1string
..... receiver.organization.streetAddressLineStrasse, Hausnummer, Postfach etc.0..*string
..... receiver.organization.postalCodePLZ0..1string
..... receiver.organization.cityOrt0..1string
..... receiver.organization.countryLand0..1string
... patientPatient1..1group
.... patient.familyNameName0..1string
.... patient.maidenNameLedigname0..1string
.... patient.givenNameVorname0..1string
.... patient.localPidLokale Patienten-ID0..1string
.... patient.birthDateGeburtsdatum0..1date
.... patient.genderGeschlecht0..1choiceOptions: 3 options
.... patient.maritalStatusZivilstand0..1choiceDefinition: Patient.maritalStatus
Options: 8 options
.... patient.phoneTelefon0..1string
.... patient.emailE-Mail0..1string
.... patient.streetAddressLineStrasse, Hausnummer, Postfach etc.0..*string
.... patient.postalCodePLZ0..1string
.... patient.cityOrt0..1string
.... patient.countryLand0..1string
.... patient.languageOfCorrespondanceKorrespondenssprache0..1choiceDefinition: Patient.communication:languageOfCorrespondance
Value Set: DocumentEntry.languageCode
.... patient.contactpersonKontaktperson0..1groupDefinition: Patient.contact
..... patient.contactperson.relationshipBeziehung0..1stringDefinition: Patient.contact.relationship.text
..... patient.contactperson.familyNameName0..1stringDefinition: Patient.contact.name.family
..... patient.contactperson.givenNameVorname0..1stringDefinition: Patient.contact.name.given
..... patient.contactperson.phoneTelefon0..*stringDefinition: Patient.contact.telecom.value
..... patient.contactperson.emailE-Mail0..1stringDefinition: Patient.contact.telecom.value
.... sender.authorVerantwortlicher1..1group
..... sender.author.practitionerVerantwortliche Person0..1group
...... sender.author.practitioner.titleTitel0..1string
...... sender.author.practitioner.familyNameName0..1string
...... sender.author.practitioner.givenNameVorname0..1string
...... sender.author.practitioner.glnGLN0..1string
...... sender.author.practitioner.zsrZSR0..1string
...... sender.author.practitioner.phoneTelefon0..1string
...... sender.author.practitioner.emailE-Mail0..1string
..... sender.author.organizationVerantwortliche Organisation0..1group
...... sender.author.organization.nameName der Organisation0..1string
...... sender.author.organization.streetAddressLineStrasse, Hausnummer, Postfach etc.0..*string
...... sender.author.organization.postalCodePLZ0..1string
...... sender.author.organization.cityOrt0..1string
...... sender.author.organization.countryLand0..1string
.... sender.dataentererErfasser0..1group
..... sender.dataenterer.practitionerErfassende Person0..1group
...... sender.dataenterer.practitioner.familyNameName0..1string
...... sender.dataenterer.practitioner.givenNameVorname0..1string
...... sender.dataenterer.practitioner.phoneTelefon0..1string
...... sender.dataenterer.practitioner.emailE-Mail0..1string
... receiverCopiesKopieempfänger0..1group
.... receiverCopyKopieempfangende Organisation oder Person0..*groupDefinition: PractitionerRole
..... receiverCopy.organization.nameName der Organisation0..1stringDefinition: PractitionerRole.practitioner
...... receiverCopy.practitionerRole.practitioner.titleTitel0..1stringDefinition: HumanName.prefix
...... receiverCopy.practitionerRole.practitioner.familyNameName0..1stringDefinition: HumanName.family
...... receiverCopy.practitionerRole.practitioner.givenNameVorname0..1stringDefinition: HumanName.given
...... receiverCopy.practitionerRole.practitioner.phoneTelefon0..1stringDefinition: ContactPoint.value
...... receiverCopy.practitionerRole.practitioner.emailE-Mail0..1stringDefinition: ContactPoint.value
..... receiverCopy.titleTitel0..1stringDefinition: PractitionerRole.organization
...... receiverCopy.practitionerRole.organization.nameName der Organisation0..1stringDefinition: Organization.name
...... receiverCopy.practitionerRole.organization.streetAddressLineStrasse, Hausnummer, Postfach etc.0..*stringDefinition: Address.line
...... receiverCopy.practitionerRole.organization.postalCodePLZ0..1stringDefinition: Address.postalCode
...... receiverCopy.practitionerRole.organization.cityOrt0..1stringDefinition: Address.city
...... receiverCopy.practitionerRole.organization.countryLand0..1stringDefinition: Address.country
..... receiverCopy.familyNameName0..1string
..... receiverCopy.givenNameVorname0..1string
..... receiverCopy.phoneTelefon0..1string
..... receiverCopy.emailE-Mail0..1string
..... receiverCopy.streetAddressLineStrasse, Hausnummer, Postfach etc.0..*string
..... receiverCopy.postalCodePLZ0..1string
..... receiverCopy.cityOrt0..1string
..... receiverCopy.countryLand0..1string
.... receiverCopy.patientPatient selbst0..1booleanDefinition: Patient
.... receiverCopy.relatedPersonAndere Person0..*groupDefinition: RelatedPerson
..... receiverCopy.relatedPerson.familyNameName0..1stringDefinition: RelatedPerson.name.family
..... receiverCopy.relatedPerson.givenNameVorame0..1stringDefinition: RelatedPerson.name.given
..... receiverCopy.relatedPerson.phoneTelefon0..*stringDefinition: RelatedPerson.telecom.value
..... receiverCopy.relatedPerson.emailE-Mail0..1stringDefinition: RelatedPerson.telecom.value
..... receiverCopy.relatedPerson.streetAddressLineStrasse, Hausnummer, Postfach etc.0..*stringDefinition: RelatedPerson.address.line
..... receiverCopy.relatedPerson.postalCodePLZ0..1stringDefinition: RelatedPerson.address.postalCode
..... receiverCopy.relatedPerson.cityOrt0..1stringDefinition: RelatedPerson.address.city
..... receiverCopy.relatedPerson.countryLand0..1stringDefinition: RelatedPerson.address.country
... consentEinverständniserklärung0..1groupDefinition: http://fhir.ch/ig/ch-lab-order/StructureDefinition/ch-lab-order-servicerequest#ServiceRequest.supportingInfo
.... consent.treatmentEinverständnis des Patienten zur Behandlung0..1string
.... consent.patientPrivacyEinverständnis des Patienten zum Datenschutz0..1string
.... consent.researchEinverständnis des Patienten zur Forschung0..1string
.... consent.advancedCareDirectivePatientenverfügung0..1string
... coverageKostenträger0..1groupDefinition: http://fhir.ch/ig/ch-lab-order/StructureDefinition/ch-lab-order-servicerequest#ServiceRequest.insurance
.... coverage.uvgUnfallversicherung (nach UVG)0..1string
.... coverage.kvgGrundversicherung (nach KVG)0..1string
.... coverage.vvgZusatzversicherung (nach VVG)0..1string
.... coverage.vvgOtherAndere (nach VVG)0..1string
... previousResultVorheriges Untersuchungsresultat0..1groupDefinition: http://fhir.ch/ig/ch-lab-order/StructureDefinition/ch-lab-order-servicerequest#ServiceRequest.supportingInfo
.... previousResult.resultUntersuchungsresultat0..*string
... hematologyHematology0..1group
.... hemato-subsetHämatologie Subset0..*choiceOptions: 5 options
... coagulationCoagulation0..1group
.... d-dimerD-Dimer0..*choiceOptions: 1 option
... ccclinical chemistry0..1group
.... crpCRP0..*choiceOptions: 4 options

doco Documentation for this format

Option Sets

Answer options for order.priority

  • iconhttp://hl7.org/fhir/request-priority#routine ("Routine")
  • iconhttp://hl7.org/fhir/request-priority#urgent ("Urgent")
  • iconhttp://hl7.org/fhir/request-priority#asap ("ASAP")
  • iconhttp://hl7.org/fhir/request-priority#stat ("STAT")

Answer options for patient.gender

  • iconhttp://hl7.org/fhir/administrative-gender#male ("Male")
  • iconhttp://hl7.org/fhir/administrative-gender#female ("Female")
  • iconhttp://hl7.org/fhir/administrative-gender#other ("Other")

Answer options for patient.maritalStatus

  • http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#1 ("ledig")
  • http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#2 ("verheiratet")
  • http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#3 ("verwitwet")
  • http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#4 ("geschieden")
  • http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#5 ("unverheiratet")
  • http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#6 ("in eingetragener Partnerschaft")
  • http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#7 ("aufgelöste Partnerschaft")
  • http://fhir.ch/ig/ch-core/CodeSystem/ech-11-maritalstatus#9 ("unbekannt")

Answer options for hemato-subset

  • http://loinc.org#24360-0 ("Hemoglobin and Hematocrit panel - Blood")
  • http://loinc.org#43113-0 ("Hemoglobin electrophoresis panel in Blood")
  • http://loinc.org#57021-8 ("CBC W Auto Differential panel - Blood")
  • http://loinc.org#58410-2 ("CBC panel - Blood by Automated count")
  • http://loinc.org#57023-4 ("Auto Differential panel - Blood")

Answer options for d-dimer

  • http://loinc.org#55398-2 ("Short Fibrin D-dimer FEU and DDU panel - Platelet poor plasma")

Answer options for crp

  • iconhttp://loinc.org#1988-5 ("C reactive protein [Mass/Volume] in Serum or Plasma")
  • iconhttp://loinc.org#76485-2 ("C reactive protein [Moles/volume] in Serum or Plasma")
  • iconhttp://loinc.org#30522-7 ("C reactive protein [Mass/volume] in Serum or Plasma by High sensitivity method")
  • iconhttp://loinc.org#76486-0 ("C reactive protein [Moles/volume] in Serum or Plasma by High sensitivity method")

7. http://example.com/fhir/QuestionnaireResponse/1-tvt (QuestionnaireResponse/1-tvt)

LinkIdTextDefinitionAnswerdoco
.. 1-tvtQuestionnaireResponse
... orderAuftrag
... receiverEmpfänger
... patientPatient
... receiverCopiesKopieempfänger
... hematologyHematology
... coagulationCoagulation
... ccclinical chemistry

doco Documentation for this format

8. http://example.com/fhir/ServiceRequest/1-tvt (ServiceRequest/1-tvt)

Generated Narrative: ServiceRequest

Resource ServiceRequest "1-tvt"

Profile: CH ORF ServiceRequest

identifier: Placer Identifier: 123

status: ACTIVE

intent: ORIGINALORDER

category: Anforderung Laboruntersuchung (ch-lab-order-servicerequest-categories#RequestForLabExam)

priority: URGENT

code: Hemoglobin and Hematocrit panel - Blood (LOINC#24360-0; LOINC#43113-0 "Hemoglobin electrophoresis panel in Blood"; LOINC#57021-8 "CBC W Auto Differential panel - Blood"; LOINC#58410-2 "CBC panel - Blood by Automated count"; LOINC#57023-4 "Auto Differential panel - Blood"; LOINC#55398-2 "Short Fibrin D-dimer FEU and DDU panel - Platelet poor plasma"; LOINC#1988-5 "C reactive protein [Mass/Volume] in Serum or Plasma")

subject: See above (Patient/HansGuggindieluft)

requester: See above (PractitionerRole/MarcMustermannArztpraxis)

insurance: Coverage/HealthInsuranceCard

specimen: