Case study 3 Annual gynaecological check-up The doctor`s assistent of the gynaecology department in the Olten group practice, Dr Peter Pap, prepares the next day`s consultations. As the practice only has a minimal laboratory of its own, certain patients are sent to the nearby Pipette laboratory outpatient clinic before the appointment, including the young patient Ms Marina Rubella, born 8. 8. 1992. In her practice software, the MPA prescribes the standard analyses agreed with the laboratory for the gynaecological 3-year check-up for patient Rubella. This also includes the Blood sample for the serotonary for any follow-up prescriptions. The laboratory transmits the results to the practice no later than 90 minutes after the Blood sample has been taken. Dr Pap prescribes the following orders during the consultation: Gynaecological cervical cytology: Pap smear - if indicated, detection and typing of HPV (human papilloma virus) should also be performed. Collection material according to the laboratory`s instructions. The cytological examination is carried out in the Pipette laboratory. The Pipette laboratory does not perform the typing itself. Partial urine status (Combur9 test): carried out by the MPA in the practice: the following parameters are examined: pH, leucocytes, erythrocytes, nitrite, protein, glucose, ketones, urobilinogen, bilirubin (semi-quantitative examinations, results are probably entered manually into the practice laboratory system). Urine bacteriology: collection material according to the laboratory`s instructions. General bact, incl. fungi to the laboratory pipette Transmission of the order is triggered by the MPA (collection time) Supplementary order “Screening before pregnancy”: All tests can be carried out from the materials (serum, EDTA Blood) taken in advance in the outpatient clinic (hepatitis-Bc antibodies, HIV 1+2 (Ak+p24), rubella IgG, lues/syphilis screening test) Mammography: Order for the Dr. Curie X-ray Institute.
Laboratory Order with Service Request 3-gyn
id: MarinaRubella meta: identifier: 80756011110123400005 name: MarinaRubella gender: FEMALE birthDate: Aug 08, 1992 maritalStatus: verheiratet (Details : {$ech-11-maritalstatus code '2' = '2', given as 'verheiratet'}) Communications - Language Preferred * Italienisch (Schweiz) (Details : {urn:ietf:bcp:47 code 'it-CH' = 'Italian (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 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: Practitioner PeterPap Profile: CH Core Practitioner identifier: GLN/7601003050707, urn:oid:2.16.756.5.30.1.123.100.2.1.1/A000001 name: Peter Pap (Official) telecom: ph: 032 333 22 40(Work), peter.pap@gruppenpraxis.ch
Generated Narrative: PractitionerRole PeterPapGruppenpraxis Profile: CH Core PractitionerRole practitioner: Practitioner Peter Pap (official) organization: Organization Gruppenpraxis Olten
Generated Narrative: Specimen Cervix-swab identifier: 48736-12345-12345 accessionIdentifier: 4e88a-12345-aa222 status: Available type: Combined specimen of cytologic material from endocervix, ectocervix, and vaginal fornix (specimen) subject: Marina Rubella (official) Female, DoB: 1992-08-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400005) request: ServiceRequest Pap smear tests - FPAR 2.0 set Collections - Collector Collected[x] * Practitioner Peter Pap (official) 2015-08-16 06:40:17+0000 Containers - Type * General specimen container (physical object)
Combined specimen of cytologic material from endocervix, ectocervix, and vaginal fornix (specimen)
General specimen container (physical object)
Generated Narrative: Specimen Blood-gyn status: Available type: Blood sample subject: Marina Rubella (official) Female, DoB: 1992-08-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400005) request: ServiceRequest Obstetric 1996 Pnl Ser+Bld Collections - Collector Collected[x] BodySite * Practitioner Peter Pap (official) 2015-08-16 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: Specimen Serum-gyn identifier: 48736-12345-75465 accessionIdentifier: 4e88a-12345-dd888 status: Available type: Serum specimen (specimen) subject: Marina Rubella (official) Female, DoB: 1992-08-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400005) request: ServiceRequest Obstetric 1996 Pnl Ser+Bld Collections - Collector Collected[x] BodySite FastingStatus[x] * Practitioner Peter Pap (official) 2015-08-16 06:40:17+0000 Structure of median cubital vein (body structure) Patient was fasting prior to the procedure. Containers - Type * General specimen container (physical object)
Structure of median cubital vein (body structure)
Patient was fasting prior to the procedure.
Generated Narrative: Specimen Urine-gyn identifier: 11111-15394-75465 accessionIdentifier: 22222-bc987-dd888 status: Available type: Urine sample subject: Marina Rubella (official) Female, DoB: 1992-08-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400005) receivedTime: 2023-12-01 16:40:17+0000 request: ServiceRequest Urinalysis dipstick panel - Urine by Automated test strip Collections - Collector Collected[x] * Practitioner Peter Pap (official) 2023-12-01 06:40:17+0000 Containers - Identifier Description Type * 4e88a-bc987-dd888-12345-urin Uriswab™ : Urine Collection System Urine specimen container (physical object)
Urine specimen container (physical object)
Generated Narrative: ServiceRequest 3-gyn-service-request-smear-test Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 status: Active intent: Original Order priority: Routine code: Pap smear tests - FPAR 2.0 set subject: Marina Rubella (official) Female, DoB: 1992-08-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400005) requester: PractitionerRole reasonCode: Routine gynecologic examination (procedure) specimen: Specimen: identifier = 48736-12345-12345; accessionIdentifier = 4e88a-12345-aa222; status = available; type = Combined specimen of cytologic material from endocervix, ectocervix, and vaginal fornix (specimen)
Routine gynecologic examination (procedure)
Generated Narrative: ServiceRequest 3-gyn-service-request-hpv Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 status: Active intent: Original Order priority: Routine code: Human papilloma virus 16+18 Ag [Presence] in Cervix subject: Marina Rubella (official) Female, DoB: 1992-08-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400005) requester: PractitionerRole reasonCode: Routine gynecologic examination (procedure) specimen: Specimen: identifier = 48736-12345-12345; accessionIdentifier = 4e88a-12345-aa222; status = available; type = Combined specimen of cytologic material from endocervix, ectocervix, and vaginal fornix (specimen)
Human papilloma virus 16+18 Ag [Presence] in Cervix
Generated Narrative: ServiceRequest 3-gyn-service-request-urine-panel Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 status: Active intent: Original Order priority: Routine code: Urinalysis dipstick panel - Urine by Automated test strip subject: Marina Rubella (official) Female, DoB: 1992-08-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400005) requester: PractitionerRole reasonCode: Routine gynecologic examination (procedure) specimen: Specimen: identifier = 11111-15394-75465; accessionIdentifier = 22222-bc987-dd888; status = available; type = Urine sample; receivedTime = 2023-12-01 16:40:17+0000
Urinalysis dipstick panel - Urine by Automated test strip
Generated Narrative: ServiceRequest 3-gyn-service-request-obstetric-panel Profile: CH LAB-Order-SR identifier: Placer Identifier/Y274589 status: Active intent: Original Order priority: Routine code: Obstetric 1996 Pnl Ser+Bld subject: Marina Rubella (official) Female, DoB: 1992-08-08 ( urn:oid:2.16.756.5.30.1.123.100.1.1.1#80756011110123400005) requester: PractitionerRole reasonCode: Routine gynecologic examination (procedure) specimen: Specimen: status = available; type = Blood sample; note = Specimen is grossly lipemic Specimen: identifier = 48736-12345-75465; accessionIdentifier = 4e88a-12345-dd888; status = available; type = Serum specimen (specimen)