Case study chronic renal insufficiency Best practice example: Control of Anticoagulation effect Mrs Birgit Blum had an unfortunate fall while skiing and sustained a open tibial plateau fracture. She was transferred to the Kantonsspital, a centre hospital, by helicopter and is waiting there for her operation. The patient is administered Liquemin 5000 E s.c. daily to prevent thromboembolic events, and the effect. To monitor the effect of this treatment, regular blood tests are carried out to determine anti-Xa activity. A special sample vessel with citrate additive is used for this purpose. The sample must be centrifuged and cooled within one hour.
Laboratory Order by Service Request 0-best-practice
id: BirgitBlum meta: identifier: 80756011110123400002 name: Birgit Blum gender: FEMALE birthDate: Jan 01, 1981 maritalStatus: unverheiratet (Details : {$ech-11-maritalstatus code '5' = '5', given as 'unverheiratet'}) Communications - Language Preferred * Deutsch (Schweiz) (Details : {urn:ietf:bcp:47 code 'de-CH' = 'German (Region=Schweiz)) true
Generated Narrative: Practitioner MarcMustermann Profile: CH Core Practitioner identifier: GLN/7601000050700, urn:oid:2.16.756.5.30.1.123.100.2.1.1/L248519 name: Marc Mustermann (Official) telecom: ph: 033 444 22 11(Work), marc.mustermann@gruppenpraxis.ch
Generated Narrative: Organization Gruppenpraxis Profile: CH Core Organization EPR identifier: GLN/7601000241115 name: Gruppenpraxis Olten telecom: +41555556677, info@gruppenpraxis.ch, http://www.gruppenpraxis.ch address: Gerbergasse 12 Olten 4600 CH
Generated Narrative: PractitionerRole MarcMustermannGruppenpraxis Profile: CH Core PractitionerRole practitioner: Practitioner Marc Mustermann (official) organization: Organization Gruppenpraxis Olten
Generated Narrative: Practitioner HansHauser Profile: CH Core Practitioner identifier: GLN/7601000050700, urn:oid:2.16.756.5.30.1.123.100.2.1.1/L248519 name: Hans Hauser (Official) telecom: ph: 038 888 22 11(Work), hans.hauser@gruppenpraxis.ch
Generated Narrative: Organization Kantonsspital Profile: CH Core Organization identifier: GLN/7601000235503 name: Kantonsspital Zug telecom: +41 45 334 55 66, info@kantonsspital.zug.ch, http://www.kanstonsspital.zug.ch address: Seestrasse 14 Postfach 14 Zug 8000 Schweiz (work)
Generated Narrative: PractitionerRole HansHauserKantonsspital Profile: CH Core PractitionerRole practitioner: Practitioner Hans Hauser (official) organization: Organization Kantonsspital Zug
Generated Narrative: Practitioner EvaErlenmeyer Profile: CH Core Practitioner identifier: GLN/7601000050717, urn:oid:2.16.756.5.30.1.123.100.2.1.1/Y274589 name: Eva Erlenmeyer (Official) telecom: ph: 033 444 55 66(Work), eva.erlenmeyer@labor-pipette.ch
Generated Narrative: Organization LaborPipette Profile: CH Core Organization identifier: GLN/7601000234407 name: Labor Pipette telecom: +41223345566, info@labor-pipette.ch, http://www.labor-pipette.ch address: Laborstrasse 23 Olten 4600 CH
Generated Narrative: PractitionerRole EvaErlenmeyerLaborPipette Profile: CH Core PractitionerRole identifier: urn:oid:2.16.756.5.30.1.123.100.2.1.1/K333333 practitioner: Practitioner Eva Erlenmeyer (official) organization: Organization Labor Pipette
Generated Narrative: Encounter FirstEncounter status: In Progress class: ActCode IMP: inpatient encounter subject: Birgit Blum Female, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400002)
Generated Narrative: Medication Liquemin Profile: CH LAB-Order Medication code: LIQUEMIN Inj Lös 25000 IE/5ml status: Active form: Conventional release solution for injection (dose form) Ingredients - Item[x] Strength * Heparin (substance) 5000 international unit (Details: UCUM code[iU] = '[iU]')/0.5 milliliter (Details: UCUM codemL = 'mL') Batches - LotNumber ExpirationDate * 9494788 2024-05-22
Conventional release solution for injection (dose form)
Generated Narrative: Specimen Serum-0-best-practice identifier: 48736-12345-75465 accessionIdentifier: 4e88a-12345-dd888 status: Available type: Serum specimen (specimen) subject: Birgit Blum Female, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400002) Collections - Collector Collected[x] BodySite FastingStatus[x] * Practitioner Marc Mustermann (official) 2023-12-01 16:40:17+0000 Structure of median cubital vein (body structure) Patient was fasting prior to the procedure. Containers - Description Type * General specimen container (physical object) General specimen container (physical object)
Structure of median cubital vein (body structure)
Patient was fasting prior to the procedure.
General specimen container (physical object)
Generated Narrative: Specimen Blood-coag-0-best-practice identifier: 48736-55555-75465 accessionIdentifier: 4e88a-66666-dd888 status: Available type: Blood sample subject: Birgit Blum Female, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400002) receivedTime: 2023-12-01 16:40:17+0000 Collections - Collector Collected[x] * Practitioner Marc Mustermann (official) 2023-12-01 17:00:17+0000 Processings - Description Time[x] * Needs to be centrifugated and cooled within 1 hour 2023-12-01 17:00:17+0000 --> 2023-12-01 17:30:17+0000 Containers - Identifier Description Type Additive[x] * 4e88a-bc987-dd888-00001-bcoag Blood collection Luer adaptor, 3.8% Citrate Blood collection Luer adaptor 3.8% Citrate
Needs to be centrifugated and cooled within 1 hour
Blood collection Luer adaptor, 3.8% Citrate
Generated Narrative: Specimen Blood-0-best-practice identifier: 48736-55555-75465 accessionIdentifier: 4e88a-66666-dd888 status: Available type: Blood sample subject: Birgit Blum Female, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400002) Collections - Collector Collected[x] BodySite * Practitioner Marc Mustermann (official) 2023-12-01 06:40:17+0000 Structure of superficial vein of left upper limb (body structure) Containers - Type * General specimen container (physical object) note: Specimen is grossly lipemic
Structure of superficial vein of left upper limb (body structure)
Generated Narrative: ServiceRequest 0-best-practice-ServiceRequest-0 Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 status: Active intent: Original Order priority: Urgent code: Deep vein thrombosis screening (procedure) subject: Birgit Blum Female, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400002) encounter: Encounter: status = in-progress; class = inpatient encounter (ActCode#IMP) requester: PractitionerRole supportingInfo: Condition Open fracture of tibial plateau (disorder)
Deep vein thrombosis screening (procedure)
Generated Narrative: ServiceRequest 0-best-practice-ServiceRequest-1 Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest Deep vein thrombosis screening (procedure) status: Active intent: Original Order priority: Urgent code: Coagulation factor X activated inhibitor [Mass/volume] in Platelet poor plasma subject: Birgit Blum Female, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400002) requester: PractitionerRole reasonCode: Patient gets Heparin injections reasonReference: Condition Prophylactic anticoagulation given (situation) supportingInfo: Medication LIQUEMIN Inj Lös 25000 IE/5ml specimen: Specimen: identifier = 48736-55555-75465; accessionIdentifier = 4e88a-66666-dd888; status = available; type = Blood sample; receivedTime = 2023-12-01 16:40:17+0000
Coagulation factor X activated inhibitor [Mass/volume] in Platelet poor plasma
Generated Narrative: ServiceRequest 0-best-practice-ServiceRequest-2 Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest Deep vein thrombosis screening (procedure) status: Active intent: Original Order priority: Urgent code: Glucose [Moles/volume] in Serum or Plasma --pre dose glucose subject: Birgit Blum Female, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400002) requester: PractitionerRole reasonCode: Diabetes mellitus screening specimen: Serum specimen
Glucose [Moles/volume] in Serum or Plasma --pre dose glucose
Generated Narrative: ServiceRequest 0-best-practice-ServiceRequest-3 Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest Deep vein thrombosis screening (procedure) status: Active intent: Original Order priority: Urgent code: Hemoglobin and Hematocrit panel - Blood subject: Birgit Blum Female, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400002) requester: PractitionerRole reasonCode: Anemia screening
Generated Narrative: ServiceRequest 0-best-practice-ServiceRequest-3-Hb Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest Hemoglobin and Hematocrit panel - Blood status: Active intent: Original Order priority: Urgent code: Hemoglobin [Mass/volume] in Blood subject: Birgit Blum Female, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400002) requester: PractitionerRole specimen: Specimen: identifier = 48736-55555-75465; accessionIdentifier = 4e88a-66666-dd888; status = available; type = Blood sample; note = Specimen is grossly lipemic
Generated Narrative: ServiceRequest 0-best-practice-ServiceRequest-3-Ht Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 basedOn: ServiceRequest Hemoglobin and Hematocrit panel - Blood status: Active intent: Original Order priority: Urgent code: Hematocrit [Volume Fraction] of Blood by calculation subject: Birgit Blum Female, DoB: 1984-01-01 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400002) requester: PractitionerRole specimen: Specimen: identifier = 48736-55555-75465; accessionIdentifier = 4e88a-66666-dd888; status = available; type = Blood sample; note = Specimen is grossly lipemic
Hematocrit [Volume Fraction] of Blood by calculation
Generated Narrative: Condition ConditionTibiaFracture Profile: CH LAB-Order Diagnosis Condition clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item severity: Severe (severity modifier) (qualifier value) code: Open fracture of tibial plateau (disorder) bodySite: Bone structure of proximal left tibia (body structure) subject: Birgit Blum encounter: Encounter: status = in-progress; class = inpatient encounter (ActCode#IMP) onset: 2024-02-05 recordedDate: 2024-02-05 asserter: Birgit Blum Evidences - Code * Open fracture of upper end of tibia (disorder)
Severe (severity modifier) (qualifier value)
Open fracture of tibial plateau (disorder)
Bone structure of proximal left tibia (body structure)
Open fracture of upper end of tibia (disorder)
Generated Narrative: Condition ConditionAnticoagulation Profile: CH LAB-Order Diagnosis Condition clinicalStatus: Active verificationStatus: Confirmed category: Problem List Item code: Prophylactic anticoagulation given (situation) subject: Birgit Blum encounter: Encounter: status = in-progress; class = inpatient encounter (ActCode#IMP) onset: 2024-02-05 recordedDate: 2024-02-05 asserter: Birgit Blum Evidences - Code * Open fracture of upper end of tibia (disorder)
Prophylactic anticoagulation given (situation)